Skip to main content

Full text of "Transactions - American Surgical Association, 1901"

See other formats


;t    fir        ,       .  ,. 


X3r.!¥"K 


■HI  N 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

University  of  Toronto 


littp://www.arcliive.org/details/transactamersurg19ameruoft 


4 


'/ 


^/ 


TRANSACTIONS 


OF  THE 


AMERICAN 
SURGICAL  ASSOCIATION. 

VOLUME   THE  NINETEENTH. 

Edited  by 
RICHARD  H.  HARTE,  M.D., 

RECORDER   OF   THE  ASSOCIATION. 


PRINTED     FOR     THE     ASSOCIATION, 

rOR   SALE   BY 

WILLIAM    J.    DORNAN,    PHILADELPHIA. 

I  90  I  . 


Copyright,  1901,  by  RICHARD  H.  Harte,  M.D.,  Recorder  of  the  Association. 


ID 
I 

m 


DORNAN.    PRINTER, 

701-709    ARCH    STREET. 

PHILADELPHIA. 


CONTENTS. 


Officers  of  the  Association ix 

List  of  Presidents  of  the  Association xi 

Fellows  of  the  Association     .........     xiii 

Honorary  Fellows xxvii 


Address  of  the  President.  The  Recent  Buffalo  Investigations  Regard- 
ing the  Nature  of  Cancer.     By  Roswell  Park,  M.D.     .        .        .         i 

The  Early  Signs  of  Carcinoma  of  the  Uterus.  By  Thomas  S.  Cul- 
LEN,  M.D 24 

Brief  Consideration  of  Cases  of  Cancer  of  the  Breast  Treated  at  the 
Johns  Hopkins  Hospital  Since  1889.     By  W.  S.  Halsted,  M.D.     .       26 

Late  Results  of  the  Treatment  of  Inoperable  Sarcoma  with  the  Mixed 
Toxins  of  Erysipelas  and  Bacillus  Prodigiosus.  By  William  B. 
CoLEY,  M.D 27 

The  Influence  of  Mental  Depression  on  the  Development  of  Malig- 
nant Disease.     By  Joseph  D.  Bryant,  M.D.  .         ...      43 

The  Cause  of  Cancer.     By  Thomas  S.  Cullen,  M.D.         .        •         •       57 

The  Clinical  Value  of  Blood  Examinations  in  Appendicitis  :  A  Study 
Based  on  the  Examination  of  One  Hundred  and  Eighteen  Cases 
in  the  German  Hospital,  Philadelphia.  By  J.  C.  Da  Costa.  Jr., 
M.D 60 

The  Blood  Changes  Induced  by  the  Administration  of  Ether  as  an 
Anaesthetic.  By  John  Chalmers  Da  Costa,  M.D.,  and  Fred- 
erick J.  Kalteyer,  M.D .        .        .72 

Studies  of  the  Blood  in  its  Relation  to  Surgical  Diagnosis.  By  R.  C. 
Cahot.  M.D.,  J.  C.  Hubbard,  M.D.,  and  J.  B.  Blake,  M.D.        .     104 

The  Examination  of  the  Blood  in  Relation  to  Surgery  of  Scientific  but 
Often  of  No  Practical  Value,  and  May  Misguide  the  Surgeon.  By 
John  B,  Deaver,  M.D 115 

Blood  Examinations  as  an  Aid  to  Surgical  Diagnosis.  By  Joseph  C. 
Bloodgood,  M.D 122 


IV  CONTENTS. 

PAGE 

Fractures  of  the  Pelvis  from  Violence  Exerted  Through  the  Long  Axis 
of  the  Femurs,  Being  a  Comparative  Study  of  the  Relative  Strength 
of  the  Neck  of  the  Femur  and  that  of  the  Pelvis  when  the  Violence 
is  Transmitted  Through  the  Long  Axis  of  the  Former.  By  Oscar 
H.  Allis,  M.D 145 

On  Pancreatitis.     By  A.  W.  Mayo  Robson,  F.R.C.S.  .        .        .149 

The  Surgical  Treatment  of  Chronic  Ulcer  of  the  Stomach.  By  A.  W. 
Mayo  Robson,  F.R.C.S 184 

Exhibition  of  Methods  of  Medical  Instruction  in  the  Johns  Hopkins 
Medical  School  and  Hospital    .         .         .         .         .         .         .         .216 

Phlebitis  Following  Abdominal  Operations.  By  Albert  Vander 
Veer,  M.D 223 

Traumatic  Arterio-venous  Aneurisms  of  the  Subclavian  Vessels,  with 
an  Analytical  Study  of  Fifteen  Reported  Cases,  Including  One 
Operated.     By  Rudolph  Matas,  M.D 237 

An  Operation  for  the  Radical  Cure  of  Umbilical  Hernia.  By  William 
J.  Mayo,  A.M.,  M.D 296 

Prevention  and  Cure  of  Post-operative  Hernia.  By  James  E  Moore, 
M.D 307 

Fractures  and  Dislocations  of  the  Spine.     By  S.  H.  Weeks,  M.D.      .     314 

Radical  Cure  of  Inguinal  and  Femoral  Hernia,  with  a  Report  of 
Eight  Hundred  and  Forty-five  Cases.  By  William  B.  Coley, 
M.D.  . 337 

Treatment  of  Aortic  Aneurisms  by  Means  of  Silver  Wire  and  Elec 
tricity  ;  with  Report  of  Cases.     By  Leonard  Freeman,  M.D.         .     359 

Double  Renal  Calculus.     By  S.  J.  Mixter,  M.D 377 

A  New  Method  of  Closing  the  Wound  in  Thorough  Removal  of  the 
Breast.     By  S.  J.  Mixter,  M.D 380 

Resection  of  a  Large  Part  of  the  Chest  Wall  for  a  Sarcoma ;  Use  of 
Fell's  Apparatus  for  Artificial  Respiration  ;  Late  Continuous  Fever 
Due  to  Staphylococcus  Blood  Infection  ;  Successful  Use  of  the  Anti- 
streptococcic Serum  ;  Complete  Recovery.  By  W.  W.  Keen,  M.D., 
LL.D.,  F.R.C.S.  (Hon.) 383 

Artificial  Respiration  by  Direct  Intralaryngeal  Intubation  with  a  Modi- 
fied O'Dwyer  Tube  and  a  New  Graduated  Air-pump  in  its  .Applica- 
tions to  Medical  and  Surgical  Practice.    By  Rudolph  Matas,  .M.D.     392 

An  Apparatus  for  Massive  Infiltration  Anaesthesia  with  Weak  Anal- 
gesic Solutions  (Modified  Schleich  Method).  By  Rudolph  Matas, 
M.D 412 

Two  Cases  of  Vicious  Circle  After  Cja^tro-enterostomy.  By  Theo- 
dore A.  McCraw,  .M.D. 417 

Anterior  Dislocation  of  the  Tibia  Treated  by  Arlhrotomy.  By  John 
B.  Roberts,  >LI) 441 


CONTENTS, 


PAGE 


Giant  Sacrococcygeal  Tumors.  An  Account  of  One  which  Pursued 
an  Atrophic  Course.     By  Charles  A.  Powers,  M.D.      .         .        .    444 

Cicatricial  Stricture  of  the  CEsophagus.  Gastrostomy,  with  Retro- 
grade Dilatation  of  the  Stricture  by  Rubber  Tubes.  By  Henry  R. 
Wharton,  M.D 45° 

Movable  Kidney  :  Its  Cause  and  Treatment.    By  M.  L.  Harris,  M.D.     457 

Pneumotomy  for  Abscess  of  the  Lung.  With  Exhibition  of  Patient. 
By  W.  Joseph  Hearn,  M  D.,  and  W.  J.  Roe,  M.D.        .        .        .482 

Excision  of  a  Part  of  Three  Ribs  and  a  Portion  of  the  Diaphragm  for 
Sarcoma.     By  C.  B.  Porter,  M.D. 494 

Cases  of  Laceration  of  the  Spleen  and  of  the  Kidney,  Followed  by 
Recovery  After  the  Removal  of  the  Injured  Organ.  By  Samuel  J. 
Mixter,  M.D 499 

Subtrochanteric  Osteotomy  for  the  Deformity  Following  Hip  Disease. 
By  E.  H.  Bradford,  M.D .        .     502 


LIST   OF   ILLUSTRATIONS. 


Diagrammatic  Representation  of  Arterio-venous  Communication  (after 
Excision  of  Clavicle),  Matas,  251 

Treatment  of  Umbilical  Hernia,  Ochsner,  303 

Resection  of  the  Chest  Wall  for  Sarcoma,  Keen  (Figs.  1-4),  384-388. 

Experimental  Automatic  Respiratory  Apparatus,  Matas,  409 

Apparatus  for  Artificial  Respiration  in  Surgical  and  Medical  Practice 
(latest  model),  Matas,  410 

Rupture  of  the  Spleen,  Mixter,  499 


LIST   OF   PLATES 


PAGE 


Blood  Changes  Induced  by  the  Administration  of  Ether  as  an  Anaes- 
thetic, Da  Costa  and  Kalteyer  (Figs,  i  and  2)        .         .        facing     100 

Arterio-venous  Aneurisms  of  the  Subclavian  Vessels,  Matas        facing     240 

Operation  for  Radical  Cure  of  Umbilical  Hernia,  Mayo  (Figs,  i  to  4) 

facing     ici(y 

Experimental  Automatic  Respiratory  Apparatus,  Matas  (Figs,  i  and  2) 

facing    409 

Apparatus  for  Artificial  Respiration  in  Surgical  and  Medical  Practice 

(latest  model),  Matas  (Figs.  3  and  4)     .         .         .         .        fa<^i"g    410 

Apparatus  for  Rapid,  Massive  Infiltration  Anaesthesia,  Matas  (Figs,  i 

and  2) facing    413 

Anterior  Dislocation  of  the  Tibia  Treated  by  Arthrotomy,  Roberts 

(Figs.  I  to  5) facing    441 

Giant  Sacrococcygeal  Tumors,  Powers  (Figs,  i  to  9)    .         .        facing     448 

Pneumotomy  for  Abscess  of  Lung,  Hearn  and  Roe     .         .        facing     488 

Excision  of  a  Part  of  Three  Ribs  and  a  Portion  of  the  Diaphragm  for 

Sarcoma,  Porter  (Figs,  i  to  4)        .         .         .         ,         .        facing    496 


OFFICERS   OF   THE  ASSOCIATION, 
Elected  May,  1901. 


PRESIDENT. 

DE  FOREST  WILLARD,  M.D. 

VICE-PRESIDENTS. 

ROBERT  ABBE.  M.D. 
RUDOLPH  MATAS,  M.D. 

SECRETARY. 

DUDLEY  p.  ALLEN,  M.D., 

278  Prospect  Street,  Cleveland. 
TREASURER. 

GEORGE  RYERSON  F'OWLER,  M.D., 

302  Washington  Avenue,  Brooklyn. 
RECORDER. 

RICHARD   H.  HARTE,  M.D., 

1503  Spruce  Street,  Philadelphia. 
COUNCIL. 

WILLIAM  W.  KEEN.  M.D. 

ROBERT  F.  WEIR,  M.D. 

ROSWELL  PARK.  M.D. 

DE  FOREST  WILLARD,  M.D.,       ^ 

DUDLEY  P.  ALLEN,  M.D..  I 

1-  Ex-ojficto. 
G.  R.  FOWLER,  M.D.,  j  "^ 

RICHARD  H.  HARTE,  M.D.,  J 


OFFICERS    OF    THE    ASSOCIATION. 
PUBLICATION   COMMITTEE. 

RECORDER,  SECRETARY  and  TREASURER. 

COMMITTEE   ON   ANNUAL   MEETING. 

SAMUEL  J.  MIXTER,  M.D.  B.  FARQUHAR  CURTIS.  M.D. 

PRESIDENT,  SECRETARY,  RECORDER  and  CHAIRMAN 
COMMITTEE  OF  ARRANGEMENTS. 

COMMITTEE  ON  STANDARD  NOMENCLATURE  AND  STUDY  OF  TU.MORS. 

ROSWELL  PARK.  M.D.  J.  C.  WARREN,  M.D. 

W.  S.  HALSTED,   M.D.  F.  S.  DENNIS,  M.D. 

COMMITTEE  ON  ADVANCEMENT  AND  PROTECTION  OF  RESEARCH  WORK. 

ROSWELL  PARK,   M.D. 
NICHOLAS  SEXN,  M.D. 
HERBERT  L.  BURRELL,  M.D. 
W.  W.  KEEN,  M.D. 


Place  of  next  Meeting — Albany,  N.  Y.,  June  3,  4  and  5,  1902. 

COMMITTEE   OF    ARRANGEMENTS. 

A.  VANDER  VEER,  M.D. 
W.  G.  MACDONALD,  M.D. 
R.  B.   BONTECOU,  M.D. 


LIST    OF    THE    PRESIDENl'S 


ASSOCIATION  FROM  THE  TIME  OF  ITS  INSTITUTION. 


18S3 
1884 
1885 
188^) 
1887 
1888 


o.f  SAMUEL  DAVID  GROSS,  M.D.,  LL.D.,  D.C.L.  Oxon., 
LL.D.  Cantab.,  LL.D.  Edin. — Founder  of  the  Association. 
EDWARD  MOTT  MOORE,  M.D.,  LL  D. 
t  WILLIAM  THOMPSON  BRIGGS,  M.D. 
t  MOSES  GUNN,  A.M.,  M.D.,  LL.D.  ' 
t  HUNTER  McGUIRE,  M.D.,  LL.D. 
t  D.  HAYES  AGNEW,  M.D.,  LL  D. 
DAVID  WILLIAMS  CHEEVER,  M.D.,  LL.D. 

1889  t  DAVID  W.  YANDELL,  M.D. 

1890  t  CLAUDIUS  HENRY  MASTIN,  M.D.,  LL.D. 
1891.     PHINEAS  SANBORN  CONNER,  M.D.,  LL.D. 

NICHOLAS  SENN,  M.D.,  Ph.D.,  LL.D. 

J.  EWING  MEARS,  A.M.,  M.D. 

FREDERIC  SHEPARD  DENNIS,  M.D. 

LOUIS  McLANE  TIFFANY,  A.M.  Cantab.,  M.D. 

JOHN    COLLINS    WARREN,    M.D.,    LL.D.    (Jefferson), 

Hon.  F  R.C.S.  Eng. 
THEODORE  F.   PREWITT,  M.D. 
WILLIAM  W.  KEEN,  A.M.,  M.D.,  LL.D.,  Hon.  F. R.C.S. 

Eng. 
ROBERT  F.  WEIR,  M.D. 
ROSWELL  PARK,  M.D. 
DE  FOREST  WILL.ARD,  A.M.,  M.D.,  Ph.D. 


1892 

•893 
1894 

1895 
1896 

1897 
1808 


i«99 
1900 
1901 


t  Deceased. 


NOTICE. 


This  volume  of  Transactions  contains  the  papers  read   before 
the  Association  at  the  Meeting  held  May  7-9,  1901. 

The  Association  assumes  no  responsibility  for  the  statements  and 
opinions  published  in  this  volume. 


FELLOWS 

OF   THE 

AMERICAN   SURGICAL   ASSOCIATION, 

MAY,  1901. 
*  Denotes  Original  Fellows. 


ELECTED 


1890.  Abbe,  Robert,  M.D  ,  Vi.e- President,  13  West  Fiftieth  Street, 
New  York.     Surgeon  to  St.  Luke's  Hospital. 

1894.  Allen,  Dudley  P.,  A.M.,  M.D.,  Secretary,  278  Prospect 
Street,  Cleveland,  Ohio.  Professor  of  Surgery,  Medical 
Department  Western  Reserve  University  ;  Visiting  Surgeon, 
Lakeside  and  Charity  Hospitals;  Consulting  Surgeon  to  the 
Cleveland  City  Hospital. 

1890.  Allis,  Oscar  Huntington,  A.M.,  M.D.,  1604  Spruce  Street, 
Philadelphia.     Surgeon  to  the  Presbyterian  Hospital. 

1901.  Armstrong,  George  E.,  CM.,  M.D.,  320  Mountain  Street, 
Montreal.  Associate  Professor  of  Clinical  Surgery,  McGill 
University ;  Surgeon  to  the  Montreal  General  Hospital ; 
Surgeon  to  the  Western  Hospital,  Montreal. 

1882.  Barton,  James  M.,  A  M.,  M.D.,  1337  Spruce  Street,  Phila- 
delphia. Surgeon  to  the  Jtfferson  Medical  College  Hos- 
pital and  to  the  Philadelphia  Hospital. 

1896.  Baxter,  George  A.,  A.M.,  M.D.,  Chattanooga,  Tennessee. 
Professor   of  Surgery,   Chattanooga   Medical   College. 

1901.  Bell,  James,  M.D.,  873  Dorchester  Street,  Montreal. 
Professor  of  Clinical  Surgery,  McGill  University ;  Surgeon 
to  the  Royal  Victoria  Hospital. 


XIV  FELLOWS    OF    THE    ASSOCIATION. 

ELECTED 

1900.  Bevan,   Arthur    Dean,   M.D.,    100   State   Street,    Chicago. 

Associate  Professor  of  Surgery,  Rush  Medical  College,  Uni- 
versity of  Chicago;  Surgeon  Presb}terian  Hospital. 

1901.  BiNNiE,  B.  F.,  M.B.,  CM.  (Aberdeen),  12th  and  Wyandotte 

Street,  Kansas  City,   Mo.     Professor  of  Surgical  Pathology 
and  Clinical  Surgery,  Kansas  City  Medical  College. 

1 90 1.  Bloodgood,  Joseph  C,  B  S.,  M.D.,  923  North  Charles  Street, 
Baltimore,  Md.  Associate  in  Surgery  in  the  Johns  Hopkins 
University. 

1882.  Bontecou,  Reed  Brockway,  M.D.,  82  Fourth  Street,  Troy, 
N.  Y.     Surgeon  to  the  Marshall  Infirmary. 

1901.  Bosher,  Lewis  C,  M.D.,  717  Franklin  Sreet,  Richmond, 
Va.  Professor  of  Surgery,  Medical  College  of  Virginia;  Sur- 
geon to  the  Old  Dominion  Hospital. 

1890.  Bradford,  Edward  Hickling,  A.B.,  M.D.,  133  Newbury 
Street,  Boston.  Surgeon  to  the  Children's  and  the  Samari- 
tan Hospitals ;  Assistant  Professor  of  Orthopaedic  Surgery 
in  the  Harvard  University. 

1900.  Brewer,  George  Emerson,  M.D.,  68  West  Forty-sixth  Street, 
New  Yoik  City.  Junior  Surgeon  Roosevelt  Hospital;  Attend- 
ing Surgeon  City  Hospital;  Assistant  Demonstrator  of  An- 
atomy in  College  of  Physicians  and  Surgeons  (Columbia 
University),  New  York. 
*i88o.  Brinton,  John  H.,  M.D.,  1423  Spruce  Street,  Philadelphia. 
Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery 
in  the  Jefferson  Medical  College  ;  Surgeon  to  St.  Joseph's 
Hospital.      Treasurer,  1884-85. 

1895.  Bryant,  Joseph  D  ,  M.D.,  54  West  Thirty-sixth  Street,  New 
York.  Professor  of  Anatomy  and  of  Operative  and  Clinical 
Surgery,  Bellevue  Hospital  Medical  College ;  Surgeon  to 
Bellevue  and  St.  Vincent's  Hospitals ;  Consulting  Surgeon 
to  Gouverneur  Hospital,  Hospital  for  Ruptured  and  Crippled, 
St.  Joseph's  and  Hackensack  Hospitals,  Asylum  for  Insane, 
New  York,  etc. 

1882.  Bull,  William  Tillinghast,  A.B.,  M.D.,  35  West  Thirty- 
fifth  Street,  New  York.  Adjunct  Professor  of  the  Practice 
of  Surgery  and  of  Clinical  Surgery  in  the  College  of  Physi- 
cians and  Surgeons,  New  York  ;  Surgeon  to  the  New  York 
and  Sf.  Luke's  Hospitals ;  Consulting  Surgeon  to  the  Hos- 


FELLOWS    OF    THE    ASSOCIATION.  XV 

LECTED 

pital  for  Ruptured  and  Crippled,  and  to  the  New  York 
Cancer  Hospital. 

1900.  Bunts,  Frank  E.,  M.D.,Osborn  Building,  275  Prospect  Street, 
Cleveland,  Ohio.  Professor  Principles  of  Surgery  and  Clin- 
ical Surgery  in  Medical  College  of  Western  Reserve  Uni- 
versity; Visiting  Surgeon  to  St.  Vincent's  Charity  Hospital; 
Consulting  Surgeon  to  Cleveland  City  and  Lutheran  Hos- 
pitals. 

1893.  BuRRELL,  Herbert  Leslie,  M.D.  (Harvard),  22  Newbury 
Street,  Boston,  Mass.  Assistant  Professor  of  Surgery  in  Har- 
vard University  ;  Visiting  Surgeon,  Boston  City  Hospital ; 
Visiting  Surgeon,  The  Children's  Hospital ;  Consulting  Sur- 
geon, Carney  Hospital  and  the  Quincy  Hospital.  Secretary, 
1895-1901. 

1889.  Cabot,  Arthur  Tracv,  A.M.,  M.D.,  3'  Marlborough  Street, 
Boston,  Mass.  Surgeon  to  the  Massachusetts  General  Hos- 
pital. 

1885.  Carmalt,  William  H.,  A.M.,  M.D.,  87  Elm  Street,  New 
Haven,  Conn.  Professor  of  Surgery  in  Yale  University ; 
Surgeon  to  the  New  Haven  Hospital.  Vice-President, 
1895. 

1896.  Carson,  Norman  Bruce,  M.D.,  209  North  Jefferson  Avenue, 
St.  Louis,  Mo.  Professor  of  Clinical  Surgery  in  the  St. 
Louis  Medical  College ;  Surgeon  to  the  St.  Louis  and 
Mullanphy  Hospitals,  and  to  the  St.  Vincent  Insane  Asy- 
lum, etc. 

1882.  Cheever,  David  Williams,  M.D.,LL.D.,  557  Boylston  Street, 
Boston,  Mass.  Professor  of  Surgery  (Emeritus)  in  Harvard 
University  ;  Surgeon  to  the  Boston  City  Hospital.  Presi- 
dent,  1888. 

1896.  Cole,  Charles  Knox,  A.M  ,  M.D.,  Helena,  Montana.  Sur- 
geon to  St.  John's,  St.  Peter's,  and  County  Hospitals. 

1898.  Coley,  William  B  ,  M.D.,  5  Park  Avenue,  New  York. 
Attending  Surgeon  to  the  New  York  Cancer  Hospital  ; 
Assistant  Surgeon  to  the  Hospital  for  the  Ruptured  and 
Crippled. 
'i88o.  Conner,  Phineas  Sanborn,  M.D.,  LL.D.,  159  West  Ninth 
Street,  Cincinnati,  Ohio.     Professor  of  Surgery  in  the  Medi- 


XVI  FELLOWS    OF    THE    ASSOCIATION. 

ELECTED 

cal  College  of  Ohio ;  Professor  of  Surgery,  Dartmouth 
Medical  College  ;  Surgeon  to  the  Cincinnati  and  the  Good 
Samaritan  Hospitals.  President,  1891  ;  Member  of  Council, 
1883  and  1 895-1 900;  Treasurer,  1885-91 
1896.  Curtis,  Benjamin  Farquhar,  A.B.,  M.D.,  7  East  Forty-first 
Street,  New  York.  Professor  of  the  Principles  of  Surgery 
and  Clinical  Surgery,  University  and  Bellevue  Hospital 
Medical  College  of  New  York  ;  Attending  Surgeon  to  St. 
Luke's  and  Bellevue  Hospitals,  and  the  General  Memorial 
Hospital  for  Treatment  of  Cancer  and  Allied  Diseases ; 
Consulting  Surgeon  to  New  York  Orthopaedic  Hospital  and 
Dispensary. 

1896.  Gushing,  Havward  Warren,  A.B.,  M.D.,  70  Commonwealth 

Avenue,  Boston,  Mass.  Junior  Visiting  Surgeon,  Boston 
City  Hospital;  Assistant  Surgeon,  Children's  Hospital, 
Boston. 

1897.  Da  Costa,  John  Chalmers,  M.D.,  1629  Locust  Street,  Phila- 

delphia, Pa.  Clinical  Professor  of  Surgery,  Jefferson  Medi- 
cal College ;  Surgeon  to  the  Philadelphia  and  the  Phoenix- 
ville  Hospitals. 

1883.  Dandridge,  Nathaniel  Pendleton,  M.D.,  422  Broadway, 
Cincinnati,  Ohio.  Professor  of  Practice  of  Surgery  and  of 
Clinical  Surgery  in  the  M  ami  Medical  College,  Cincinnati. 
Treasurer,  1894-96. 

1892.  Deaver,  John  B.,  M  D.,  1634  Walnut  Street,  Philadelphia. 
Surgeon  to  the  German  Hospital,  Philadelphia. 

1882.  Dennis,  Frederic  Shepard,  M.D.,F.R  C.S.  Eng.,  542  Mad- 
ison Avenue,  New  York.  Professor  of  Clinical  Surgery, 
Cornell  University,  New  York  City  ;  Visiting  Surgeon  to  the 
Bellevue  and  St.  Vincent's  Hospitals;  Consulting  Surgeon 
to  St.  Joseph's  Hospital,  Yonkers,  and  Montefiore  Home, 
New  York  City.  President,  1894;  Vice-President,  1887; 
Member  of  Council,  1889. 

1899.  Dunn,  James  H.,  M.D.,  337  Oak  Grove  Street,  Minneapolis, 
Minn.  Professor  of  Practice  of  Surgery,  Medical  Depart- 
ment, University  of  Minnesota. 

1 901.  Eliot,  Ellsworth,  Jr.,  M.D.,  48  West  Thirty-Sixth  Street, 
New  York.     Clinical  Lecturer  and  Demonstrator  of  Surgery, 


FELLOWS    OF    THE    ASSOCIATION.  XVll 

LECTED 

College  of  Physicians  and  Surgeons,  New  York  ;  Surgeon  to 
the  Presbyterian  Hospital. 

1S93.  Elliot,  John  Wheelock,  A.M.,  M.D.  (Harvard),  124  Bea- 
con Street,  Boston.  Surgeon  to  Massachusetts  General  Hos- 
pital. 

1896.  EsTES,  William  Lawrence,  A.M.,  M.D.,  South  Bethlehem, 
Penna.  Director  and  Surgeon-in-Chief  of  St.  Luke's  Hos- 
pital ;  Lecturer  on  Hygiene  at  Lehigh  University. 

1898.  Eve,  Duncan,  A.M.,  M.D.,  700  Church  Street,  Nashville, 
Tenn.  Professor  of  Surgery  and  Clinical  Surgery,  Medical 
Department  Vanderbilt  University  ;  Surgeon  to  the  Nashville 
City  Hospital. 

1883.  Fencer,  Christian,  M.D.,  269  La  Salle  Avenue,  Chicago. 
Professor  of  Clinical  Surgery,  Rush  Medical  College  ;  Pro- 
fessor of  Clinical  Surgery  in  the  Northwestern  University- 
Medical  School  and  the  Chicago  Polyclinic ;  Surgeon  to 
Emergency,  German,  Mercy,  and  Norwegian  Hospitals. 
Vice-  F resident,  1895. 

1901.  Ferguson,  Alex.  Hugh,  CM.,  M.D.,  452  East  Forty-Ninth 
Street,  Chicago.  Professor  of  Clinical  Surgery  in  the  Medi- 
cal Department  of  the  University  of  the  State  of  Illinois ; 
Professor  of  Surgery  in  the  Post-Graduate  Medical  School  of 
Chicago;  Surgeon  in-Chief  of  the  Chicago  Hospital;  Sur- 
geon to  Cook  County  Hospital  for  the  Insane  ;  Consulting 
Surgeon  to  Provident  Hospital. 

1899  Finney,  John  T.,  M.D.,  1300  Eutaw  Place,  Baltimore, 
Md.  Associate  Professor  of  Surgery,  Johns  Hopkins  Uni- 
versity. 

1882.  Forbes,  William  Smith,  M.D.,  901  Pine  Street,  Philadelphia. 
Professor  of  Anatomy  in  the  Jefferson  Medical  College  of 
Philadelphia. 

1 89 1.  Fowler,  George  Ryerson,  M.D.,  Treasurer,  302  Washing- 
ton Avenue,  Borough  of  Brooklyn,  New  York  City.  Pro- 
fessor of  Surgery,  Ncat  York  Polyclinic  ;  Examiner  in  Sur- 
gery, Medical  Examining  Board  of  Regents,  University 
State  of  New  York  ;  Surgeon  to  the  Methodist  Episcopal, 
German,  and  Brooklyn  Hospitals;  Consulting  Surgeon  to 
St.  Mary's  and  Norwegian  Relief  (E.D.)  Hospitals. 

Am  Surg  B 


XVlll  FELLOWS    OF    THE    ASSOCIATION. 

BLECTBD 

1898.  Freeman,  Leonard,  B.S.,  M.D.,  California  Building,  Denver, 
Col.  Professor  of  Surgery,  Gross  Medical  College  ;  Surgeon 
to  the  Arapahoe  County  Hospital  and  to  St.  Anthony's 
Hospital. 

1 89 1.  Gaston,  James  McFadden,  A.B.,  M.D.,  421  Capitol  Avenue, 

Atlanta,  Georgia.  Professor  of  Surgery  in  Southern  Medi- 
cal College.  Vice-President,  1897. 
1882.  Gay,  George  Washington,  A.M.,  M.D.,  665  Boylston  Street, 
Boston,  Mass.  Senior  Surgeon  to  the  Boston  City  Hospital; 
Clinical  Instructor  in  Surgery  in  Harvard  University. 
Member  of  Council,  1882. 

1892.  Gerrish,  Frederic  Henry,  A.M.,  M.D.,  675  Congress  Street, 

Portland,  Maine.  Consulting  Surgeon,  Maine  General 
Hospital ;  Professor  of  Anatomy  in  Medical  Department  of 
Bowdoin  College. 
1890.  Gerster,  Arpad  G.,  M.D.,  Chir.  D.,  34  East  Seventy-fifth 
Street,  New  York.  Professor  of  Surgery  in  the  New  York 
Polyclinic ;  Surgeon  to  the  German  and  Mount  Sinai  Hospi- 
tals. 

1892.  Halsted,  William  Stewart,  B.A.,  M.D.,  1201  Eutaw  Place, 
Baltimore,  Maryland.     Surgeon  to  Johns  Hopkins  Hospital. 

1898.  Harrington,  Francis  B.,  A.B.  (Tuft's  College),  M.D. 
(Harvard  College),  201  Beacon  Street,  Boston,  Mass.  Sur- 
geon to  Massachusetts  General  Hospital. 

1901.  Harris,  Malcolm  L.,  M.D.,  100  State  Street,  Chicago,  111. 
Professor  of  Surgery  Chicago  Polyclinic  ;  Attending  Surgeon 
Alexian  Brothers'  Hospital,  St.  Luke's  Hospital,  and  Maurice 
Porter  Hospital  for  Children. 

1895.  Harte,  Richard  H.,  M.D.,  Recorder,  1503  Spruce  Street, 
Philadelphia.  Surgeon  to  the  Pennsylvania  and  Episcopal 
Hospitals  ;  Consulting  Surgeon,  St.  Mary's,  St.  Timothy's, 
and  Bryn  Mawr  Hospitals. 

1898.  Hearn,  W.  Joseph,  M.D. ,  11 20  Walnut  Street,  Philadelphia. 
Clinical  Professor  of  Surgery,  Jefferson  Medical  College ; 
Visiting  Surgeon  to  the  Philadelphia  Hospital ;  Consulting 
Surgeon  to  the  Phoenixville  General  Hospital. 

1889.  Homans,  John,  A.B.,  M.D.,  164  Beacon  Street,  Boston. 
Surgeon  to  the  Massachusetts  General  Hospital. 


FELLOWS    OF    THE     ASSOCIATION.  XIX 

ELECTED 

1899.  HoRWiTZ,  Orville,  M.D.,  1721  Walnut  Street,  Philadelphia, 
Clinical  Professor  of  Genito-Urinary  Diseases,  Jefferson 
Medical  College ;  Surgeon  to  the  Philadelphia  Hospital ; 
Consulting  Surgeon  to  State  Hospital  for  Insane  and  Hayes 
Mechanics'  Home. 

1901.  Huntington,  Thomas  W.,  A.B.,  M.D.,  406  Sutter  Street, 
San  Francisco,  California.  Professor  of  Clinical  and  Opera- 
tive Surgery,  Medical  Department  University  of  California; 
Visiting  Surgeon  to  the  City  and  County  Hospital,  San  Fran- 
cisco; Consulting  Surgeon  St.  Luke's  Hospital,  San  Francisco. 

1901.  Jacobson,  Nathan,  M.D.,  430  South  Salina  Street,  Syracuse, 
N.Y.  Professor  of  Clinical  Surgery,  College  of  Medicine, 
Syracuse  University  ;  Surgeon  to  St.  Joseph's  Hospital, 

1 90 1.  Johnson,  Alexander  B.,  M,D.,  12  East  Fifty-Eighth  Street, 
New  York.  Professor  of  Clinical  Surgery,  Cornell  University 
Medical  College ;  Attending  Surgeon  to  New  York  Hos- 
pital. 

1896.  Johnston,  George  Ben,  M.D.,  207  East  Grace  Street,  Rich- 
m.ond,  Va.  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  the  Medical  College  of  Virginia;  Sur- 
geon to  the  Old  Dominion  Hospital,  and  Consulting  Surgeon 
to  the  Richmond  City  Free  Dispensary. 

1901.  Jonas,  A.  F.,  M.D.,  Continental  Block,  Omaha,  Nebraska. 
Professor  of  Surgery,  Omaha  Medical  College ;  Surgeon  to 
the  Methodist  Episcopal  Hospital  and  to  the  Douglas  County 
Hospital. 

1899.  Kammerer,  Frederick,  M.D.,  51  East  Sixty-sixth  Street,  New 
York  City.  Professor  of  Clinical  Surgery,  Cornell  Medical 
College;  Surgeon  to  the  German  and  St.  Francis'  Hospitals, 
New  York. 
*i88o  Keen,  William  Williams,  A.M.,M.D.,  LL.D.,  Hon.  F.R.C.S. 
Eng.,  1729  Chestnut  Street,  Philadelphia.  Professor  of 
the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the 
Jefferson  Medical  College;  Surgeon  to  the  Jefferson  Medical 
College  Hospital  and  to  the  Orthopaedic  Hospital  and  In- 
firmary for  Nervous  Diseases ;  Consulting  Surgeon  to  the 
Woman's  and  St.  Agnes'  Hospitals  ;  Membre  Correspondant 


KX  FELLOWS    OF    THE    ASSOCIATION. 

BLECTED 

Etrange  de  la  Societe  de  Chirurgie  de  Paris;  Membre  Hon- 
oraire  de  la  Societe  Beige  de  Chirurgie.  Presidetit,  1898; 
Vice-President,  1892;  Member  of  Council,  1 899-1 901. 

1901.  La  Garde,  Louis  A.,  M.D.,  United  States  Soldiers'  Home, 
Washington,  D.C.  Professor  of  Military  Surgery,  New  York 
University  and  Bellevue  Hospital  Medical  College  ;  Major 
and  Surgeon  United  States  Army. 

1901.  Le  Conte,  Robert  G.,  A.B.,  M.D.,  348  South  Sixteenth 
Street,  Pniladelphia.  Surgeon  to  the  Pennsylvania,  the  Chil- 
dren's, and  the  Bryn  Mawr  Hospitals. 

1890.  Lane,  Levi  Cooper,  A.M.,  M.D.,  M.R.C.S.  Eng.,LL.D.,  San 
Francisco,  Cal.  Professor  of  Surgery  in  the  Cooper  Medi- 
cal College,  San  Francisco.      Vice-President,  1891. 

1889.  Lange,  Frederick  E.,  M.D.,  691  Lexington  Avenue,  New 
York. 

1901.  McArthur,  L.  L.,  M.D.,  4415  Drexel  Building  Chicago,  111. 
Professor  of  Clinical  Surgery,  Post-Graduate  Medical  School ; 
Assistant  Professor  of  Clinical  Surgery,  Rush  Medical  Col- 
lege ;  Surgeon  to  St.  Luke's  and  Michael  Reese  Hospitals. 

1896.  McCosH,  Andrew  J.,  B.A.,  M.D.,  16  East  Fifty-fourth  Street, 
New  York,  Surgeon  to  the  Presbyterian  Hospital ;  Clinical 
Lecturer  on  Surgery,  College  of  Physicians  and  Surgeons. 

1882.  McGraw,  Theodore  A.,  M.D.,  107  West  Fort  Street,  Detroit, 
Michigan.  Professor  of  Surgery  in  the  Detroit  Medical 
College  ;  Surgeon  to  Sr.  Mary's  and  the  Harper  Hospitals. 
Vice-President,  1896. 

1901.  Macdonald,  Willis  G.,  M.D.,  27  Eagle  Street,  Albany,  New 
York. 

1899.  Markoe,  Francis  H.,  M.D.,  15  East  Forty-ninth  Street,  New 
York.  Professor  of  Clinical  Surgery,  Medical  Department 
Columbia  University,  New  York  City;  Attending  Surgeon, 
St.  Luke's  and  New  York  Hospitals;  Consulting  Surgeon, 
Orthopaedic  Hospital. 
■1880.  Marks,  Solon,  M.D.,  136  Wisconsin  Street,  Milwaukee,  Wis. 
Surgeon  to  St.  Mary's  Hospital.      Vice-Preside?it,  1898. 

1898.  Martin,  Edward,  M.D.,  415  South  Fifteenth  Street,  Phila- 
delphia.    Clinical  Professor  of  Surgery,  University  of  Penn- 


FELLOWS    OF    THE    ASSOCIATION.  XXI 

:lkcted 

sylvania;  Clinical  Professor  of  Surgery,  Woman's  Medical 
College,  Philadelphia;  Surgeon  to  Philadelphia,  St.  Agnes', 
and  Howard  Hospitals. 
1887.  Mastin,  William  McDowell,  M.D.,  Northwest  corner  of 
Joachim  and  Conti  Streets,  Mobile,  Ala.  Surgeon  to  the 
Mobile  City  Hospital. 

1895.  Matas,  Rudolph,  M.D.,  Vice-President,  2255  St.  Charles  Ave- 

nue, New  Orleans,  La.  Professor  of  Surgery,  Medical  De- 
partment Tulane  University ;  Professor  of  Clinical  Surgery, 
New  Orleans  Polyclinic  ;  Surgeon  to  Charity  Hospital ;  Con- 
sulting Surgeon  to  the  Eye,  Ear,  Nose,  and  Throat  Hospital. 

1899.   Mavo,   William  J.,  A.M.,  M.D.,  427  West    College  Street, 

Rochester,  Minn.     Surgeon  to  St.  Mary's  Hospital. 
=  1880.  Mears,  J.  EwiNG,  A.M.,  M.D.,  1429  Walnut  Street,  Philadel- 
phia.    President,  1893;   Recorder, _i?>Si-()t,. 

1901.  Meyer,'  Willy,  M.D.,  700  Madison  Avenue,  New  York. 
Professor  of  Surgery  in  the  New  Y9rk  Post-Graduate  Medi- 
cal School  and  Hospital ;  Attending  Surgeon  to  the  German 
and  New  York  Skin  and  Cancer  Hospitals ;  Consulting  Sur- 
geon to  the  New  York  Infirmary  for  Women  and  Children. 

1893.  MixTER,  Samuel  Jason,  S.B.  (Massachusetts  Institute  of 
Technology),  M.D.  (Harvard),  180  Marlborough  Street, 
Boston.  Surgeon  to  Massachusetts  General  Hospital  and  to 
Carney  Hospital ;  Consulting  Surgeon  to  the  Massachusetts 
Charity  Eye  and  Ear  Infirmary;  Instructor  in  Surgery  in 
the  Harvard  University. 

1896.  Monks,  George  Howard,  A.B.  (Harvard),  M.D.  (Harvard), 

M.R.C.S.  Eng.,  67  Marlborough  Street,  Boston.  Surgeon 
to  Carney  Hospital ;  Assistant  Visiting  Surgeon,  Boston  City 
Hospital ;  Instructor  in  Clinical  and  Assistant  in  Operative 
Surgery,  Harvard  Medical  School ;  .Instructor  in  Surgical 
Pathology,  Harvard  Dental  School. 
1895.  Moore,  James  E.,  M.D.,  802  Dayton  Building,  Minneapolis, 
Minn.  Professor  of  Clinical  Surgery,  University  of  Minne- 
sota ;  Surgeon  to  St.  Barnabas'  and  Northwestern  Hospitals ; 
Consulting  Surgeon  to  St.  Mary's  and  City  Hospitals. 
^1880.  Morton,  Thomas  George,  M.D.,  1421  Chestnut  Street, 
Philadelphia.  Surgeon  to  the  Pennsylvania  and  Consulting 
Surgeon  to  the  Orthopaedic  and  Jewish  Hospitals. 


XXII  FELLOWS    OF    THE    ASSOCIATION. 

BLBCTED 

1898.  Morton,  Thomas  S.  K.,  M.D,,  1506  Locust  Street,  Phila- 
delphia. Professor  of  Surgery,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine;  Surgeon  to  the  Out- 
Patient  Department  of  the  Pennsylvania  Hospital ;  Consult- 
ing Surgeon  to  the  Woman's  Hospital. 

1900.  MuNRO,  John  C,  M.D.,  173  Beacon  Street,  Boston.  Instructor 
in  Surgery,  Harvard  ;  Professor  of  Surgery,  Tuft's  College 
Dental  School;  Assistant  Visiting  Surgeon,  Boston  City 
Hospital. 

1898.  Murray,  Francis  W.,   M.D.,  32   West  Thirty-ninth  Street, 

New  York  City.  Professor  of  Clinical  Surgery  in  Cornell 
University  Medical  College ;  Surgeon  to  the  New  York  and 
St.  Luke's  Hospitals. 

1882.  Nancrede,  Charles  Beylard,  A.M.  (University  of  Penn- 
sylvania), M.D.,  LL.D.  (Jefferson),  Southwest  corner  Thayer 
Street  and  South  University  Avenue,  Ann  Arbor,  Mich. 
Professor  of  Surgery  in  the  University  of  Michigan.  Vice- 
Preside?tf,  1889  and  1899. 

1900.  OcHSNER,  A.  J.,  B.S.,  F.R.M.S.,  M.D.  (Eng.),  710  Sedgwick 
Street,  Chicago.  Professor  of  Clinical  Surgery,  College  of 
Physicians  and  Surgeons ;  Surgeon-in-Chief  of  Augustana 
and  St.  Mary's  Hospitals. 

1900.  Oliver,  J.  C,  M.D.,  Berkshire  Building,  628  Elm  Street, 
Cincinnati,  Ohio.  Professor  of  Descriptive  Anatomy, 
Miami  Medical  College  ;  Surgeon  Cincinnati,  Presbyterian, 
and  Christ  Hospitals. 

1S82.  Owens,  John  E.,  M.D.,  1806  Michigan  Avenue,  Chicago. 
Professor  of  Principles  and  Practice  of  Surgery  and  Clinical 
Surgery  in  the  Chicago  Medical  College ;  Surgeon  to  St. 
Luke's  Hospital.      Vice-President ,  1900. 

1899.  Parham,  Frederick  William,  M.D.,  1429  Seventh  Street,  New 

Orleans,  La,  Professor  of  General  Clinical  and  Operative 
Surgery  on  the  Cadaver,  New  Orleans  Polyclinic;  Surgeon, 
Charity  Hospital ;  Consulting  Surgeon,  Eye,  Ear,  Nose,  and 
Throat  Hospital. 
1885.  Park,  Roswell,  A.M.,  M.D.,  510  Delaware  Avenue,  Buffalo, 
N.  Y.     Professor  of  Surgery  in  the  Medical  Department  of 


FELLOWS    OF    THE    ASSOCIATION.  XXIU 

ILBCTED 

the  University  of  Buffalo  ;  Surgeon  to  the  Buffalo  General 
Hospital ;  Consulting  Surgeon  to  the  Fitch  Accident  Hos- 
pital. President,  1900;  Vice-President,  1893;  Member  of 
Council,  1893-94,  1 90 1. 

1896.  Parkhill,  Clayton,  M.D.,  245-46  Equitable  Building,  Den- 
ver, Col.  Dean  of  the  Colorado  School  of  Medicine,  Medi- 
cal Department  of  the  University  of  Colorado,  and  Professor 
of  the  Principles  and  Practice  of  Surgery  and  Clinical  Sur- 
gery in  the  same ;  Professor  of  Surgery  in  Gross  Medical 
College,  Denver;  Surgeon  to  St.  Luke's  and  the  Arapahoe 
County  Hospitals,  Denver;  Surgeon-in  Chief  to  the  Citizens' 
Hospital,  Aspen,  Col.  ;  Consulting  Surgeon  to  the  State 
Hospital  for  the  Insane,  Pueblo,  Col.  ;  Surgeon-General  of 
the  National  Guard  of  Colorado.     Vice-President,  1900. 

1893.  Parmenter,  John,  M.D.,  519  Franklin  Street,  Buffalo,  N.  Y. 
Professor  of  Anatomy  and  Clinical  Surgery  in  the  Medical 
Department  of  the  University  of  Buffalo ;  Surgeon  to  the 
Sisters  of  Charity,  Erie  County,  Fitch,  Children's,  and 
Emergency  Hospitals;  Assistant  Surgeon,  Buffalo  General 
Hospital. 

1889.  PiLCHER,  Lewis  S.,  A.M.,  M.D.,  LL.D.  (Dickinson),  145 
Gates  Avenue,  Brooklyn,  N.Y.  Professor  of  Clinical  Surgery 
in  the  Post- Graduate  Medical  School,  New  York  ;  Surgeon 
to  the  Methodist  Episcopal  Hospital.      Vice-President,  1893. 

1887.  Porter,  Charles  Burnham,  A.M.,  M.D.  (Harvard),  5  Arling- 
ton Street,  Boston,  Mass,  Professor  of  Clinical  Surgery  in 
Harvard  University  ;  Surgeon  to  the  Massachusetts  General 
Hospital.      Vice-President,  1892. 

1882.  Porter,  William  Gibbs,  M.D.,  11 18  Spruce  Street,  Philadel- 
phia,    Surgeon  to  the  Presbyterian  Hospital. 

1896,  Powers,  Charles  A.,  M.D.,  Fourteenth  and  Stout  Streets, 
Denver,  Col.  Professor  of  Surgery  in  the  University  of 
Denver,  and  Surgeon  to  the  Arapahoe  County  Hospital  and 
to  St.  L'jke's  Hospital. 

1882.  Prewitt,  Theodore  F.,  M.D.,  3101  Pine  Street,  St.  Louis, 
Mo,  Professor  of  the  Principles  of  Surgery  in  the  Medical 
Department  of  Washington  University  ;  Surgeon  to  St.  John's 
Hospital.  President,  1897;  Vice-President,  1886;  Metnber 
of  Council,  1894-96. 


XXIV  FELLOWS    OF    THE    ASSOCIATION. 

ELECTED 

1886.  Ransohoff,    Joseph,    M.D.,    F.R.C.S.    Eng.,     706    Walnut 

Street,  Cincinnati,  Ohio.  Professor  of  Anatomy  in  the 
Medical  College  of  Ohio  ;  Surgeon  to  the  Cincinnati  and 
the  Good  Samaritan  Hospitals. 

1887.  Richardson,  Maurice  Howe,  A.B.,  M.D.,  224  Beacon  Street, 

Boston,  Mass.  Surgeon  to  the  Massachusetts  General  Hos- 
pital;  Assistant  Professor  of  Clinical  Surgery  in  Harvard 
University.      Vice-President,  1897;  Secretary,  1894-96. 

1901.  RixFORD,  Emmet,  B.S.,  M.D.,  1400  Van  Ness  Avenue,  San 
P'rancisco,  Cal.  Professor  of  Surgery  in  Cooper  Medical 
College  ;  Surgeon  to  the  City,  County,  and  Lane  Hospitals. 

1882.  Roberts,  John  B.,  A.M.,  M.D.,  1627  Walnut  Street,  Phila- 
delphia. Professor  of  Anatomy  and  Surgery  in  the  Phila- 
delphia Polyclinic  ;  Surgeon  to  the  Methodist  and  Jewish 
Hospitals.  Vice  President,  1888  and  1894;  Treasurer, 
1892-93. 

1S98.  Rodman,  William  L.,  A.M.,  M.D.,  1626  Spruce  Street, 
Philadelphia.  Professor  of  the  Principles  of  Surgery  and 
Clinical  Surgery  in  the  Medico-Chirurgical  College,  Phila- 
delphia; Professor  of  the  Principles  and  Practice  of  Surgery 
and  Clinical  Surgery  in  the  Woman's  Medical  College, 
Philadelphia. 

1882.  RusHMORE,  John  Dikeman,  M.D.,  129  Montague  Street, 
Brooklyn,  N,  Y.  Professor  of  Surgery  in  the  Long  Island 
College  Hospital ;  Surgeon  to  the  Brooklyn,  St.  Peter's, 
and  the  Eye  and  Ear  Hospitals. 

1882.  Senn,  Nicholas,  M.D.,  Ph.D.,  LL.D.  (Jefferson),  532  Dear- 
born Avenue,  Chicago,  111.  Professor  of  the  Principles  of 
Surgery  and  Clinical  Surgery  in  Rush  Medical  College; 
Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief  to  St. 
Joseph's  Hospital.    President,  1892;  Me?nber  of  Council,  i^<)'j. 

1895.  SoucHON,  Edmond,  M.D.,  135  Baronne  Street,  New  Orleans, 
La.  Professor  of  Anatomy  and  of  Clinical  Surgery,  Tulane 
University ;  Surgeon  to  Charity  Hospital ;  Consulting  Sur- 
geon to  the  Eye,  Ear,  Nose,  and  Throat  Hospital.  Vice- 
President,  1899. 

1901.  Taylor,  William  J.,  M.D.,  1825  Pine  Street,  Philadelphia. 
Surgeon    to    the    Orthopaedic    Hospital    and    Infirmary    for 


FELLOWS    OF    THE    ASSOCIATION.  XXV 

LBCTED 

Nervous  Diseases,  and  to  St.  Agnes'  Hospital ;  Consulting 
Surgeon  to  the  West  Philadelphia  Hospital  for  Women. 

1885.  Thompson,  J.  Ford,  M.D.,  1401  H  Street,  N.  W.,  Washing- 
ton, D.  C.  Professor  of  Surgery  in  tl  e  National  Medical 
College  ;  Surgeon  to  the  Garfield  Memorial  and  the  Chil- 
dren's Hospitals. 

1882.  Thomson,  William,  M.D.,  1426  Walnut  Street,  Philadelphia. 
Emeritus  Professor  of  Ophthalmology  in  the  Jefferson  Med- 
ical College. 

18S2.  Tiffany,  Louis  McLane,  A.M.  (Cantab.),  M.D.,  831  Park 
Avenue,  Baltimore,  Md.  Professor  of  Surgery  in  the  Uni- 
versity of  Maryland  ;  Surgeon  to  the  University  Hospital. 
President,    1895;   Mejnber  of  Council,  1885-89,  and  1896-7. 

1882.  Vander  Veer,  Albert,  A.M.,  M.D.,  Ph.E).,  28  Eagle  Street, 
Albany,  N.  V".  Dean  of  Albany  Medical  College;  Profes- 
sor of  Didactic  Abdominal  Surgery  and  of  Clinical  Sur- 
gery in  the  Albany  Medical  College;  Consulting  Surgeon  to 
St.  Peter's  Hospital ;  Attending  Surgeon  to  the  Albany 
Hospital.      Vice-President,  1898. 

1891.  Walker,  Edward  W.,  M.D.,  96  West  Eighth  Street,  Cin- 
cinnati, Ohio.  Professor  of  Surgery,  Miami  Medical 
College. 

1882.  Warren,  John  Collins,  M.D.,  LL.D.  (Jefferson),  Hon. 
F.R.C.S.  Eng.,  58  Beacon  Street,  Boston,  Mass.  Professor 
of  Surgery  in  Harvard  University  ;  Surgeon  to  the  Massachu- 
setts General  Hospital.  President,  1896;  Vice-President, 
1890;   Member  of  Council,  1897. 

1896.  Watson,  Francis  Sedgwick,  A.B.,  M.D.,  92  Marlborough 
Street,  Boston.  Surgeon  to  the  Boston  City  Hospital ;  In- 
structor in  Genito-Urinary  Surgery,  Harvard  Medical 
School. 

1889.  Weeks,  Stephen  H.,  M.D.,  662  Congress  Street,  Portland, 
Maine.  Professor  of  Surgery  in  the  Medical  School  of 
Maine  ;  Surgeon  to  Maine  General  Hospital.  Member  of 
Council,  1893. 

1889.  Weir,  Robert  F.,  M.D.,  11  East  Fifty-fourth  Street,  New 
York.     Professor  of  Surgery  in  the  College  of  Ph}sicians 


XXVI  FELLOWS    OF    THE    ASSOCIATION. 

ELECTED 

and  Surgeons,  Columbia  University ;  Surgeon  to  the  Roose- 
velt Hospital.  President,  1899.  Member  of  Cotincil,  1893- 
1896  and  1901. 

1892.  Wharton,  Henry  R.,  A.M.,  M.D.,  1725  Spruce  Street, 
Philadelphia.  Surgeon  to  the  Presbyterian,  Children's,  and 
Methodist  Hospitals. 

1882.  White,  J.  William,  M.U.,  Ph.D.,  1810  South  Rittenhouse 
Square,  Philadelphia.  John  Rhea  Barton  Professor  of  Sur- 
gery in  the  University  of  Pennsylvania. 

1 89 1.  Wight,  Jarvis  Sherman,  A.M.,  M.D.,  LL.D.,  30  Schermer- 
horn  Street,  Brooklyn,  N.  Y.  Professor  of  Operative  and 
Clinical  Surgery,  Long  Island  College  Hospital ;  Surgeon  to 
Long  Island  College  Hospital ;  Consulting  Surgeon  to  St. 
Mary's  Hospital. 

1882.  WiLLARD,  De  Forest,  A.M.,  M.D.  (Univ.  of  Pa.),  Ph.D., 
President,  1818  Chestnut  Street,  Philadelphia.  Clinical 
Professor  of  Orthopedic  Surgery  in  the  University  of  Penn- 
sylvania;  Surgeon  to  the  Presbyterian  Hospital;  Consulting 
Surgeon  to  the  Hospital  for  the  Chronic  Insane  of  Pennsyl- 
vania, and  to  the  New  Jersey  Training  School.  Recorder, 
1893-1900. 

1901.  WoLSEY,  George,  M.D.,  117  East  Thirty-sixth  Street,  New 
York  City.  Professor  of  Anatomy  and  Clinical  Surgery, 
Cornell  University;   Surgeon  to  Bellevue  Hospital. 


HONORARY     FELLOWS. 


ELECTED 


1885.  Annandale,  Thomas,  M.R.C.S.  Eng.,  M.D.  Edin.,  34 
Charlotte  Square,  Edinburgh,  Scotland.  Regius  Professor 
of  Clinical  Surgery  in  the  University  of  Edinburgh. 

1894.     VON  Bergmann,  Prof.   Dr.  Ernst,  Geh.  Med.  Rath.,  Klin. 

Institut  fiir  Chirurgie,  Berlin,  Germany. 
1891.     Bryant,  Thomas,  Esq.,  F.R.C.S.  Eng.,  65  Grosvenor  Street, 

Grosvenor  Square,  W.,  London. 

1891.  Chiene,  John,  F.R.C.S.  Edin.,  M.D.  Edin.,  26  Charlotte 
Square,  Edinburgh,  Scotland.  Professor  of  Surgery  in 
the  University  of  Edinburgh. 

1885.  CzERNY,  Prof.  Dr.  Vincent,  25  Sophien  Strasse,  Heidel- 
berg, Germany.  Professor  of  Surgery  in  the  University 
of  Heidelberg. 

1885.  voN  EsMARCH,  Prof.  Dr.  Friedrich,  2  Hospitalbcrg,  Kiel, 
Schleswig-Holstein,  Germany.  Professor  of  Surgery  in  the 
University  of  Kiel. 

1893.  Gussenbauer,  Prof.  Dr.   Carl,    ix.    Ferstelgasse,    Vienna. 

Imperial    and   Royal   Professor   of  Surgery  and  Chief  of 
the  Second  Surgical  Clinic  and  of  the  Surgical  Institute. 

1891.  Harrison,  Reginald,  Esq.,  F.R.C.S.  Eng.,  6  Lower  Berk- 
eley Street,  Portman  Square,  W.,  London. 

1890.  Horsley,  Victor  Alexander  Haden,  F.R.C.S.  Eng.,  25 
Cavendish  Square,  W.,  London. 

1883.  Horwitz,  p.  J.,  M.D.,  1919  Walnut  Street,  Medical  Director 
U.  S.  Navy  (Retired),  Philadelphia. 

1894.  Kocher,  Prof.  Dr.  Theodor,  Professor  of  Surgery,  Univer- 

sity of  Berne,  Villette  25,  Berne,  Switzerland. 

1885.  Lister,  Lord  Joseph,  F.R.C.S.  Eng.,  D.C.L.,  LL.D.,  12 
Park  Crescent,  London,  N.  W.  Professor  of  Clinical  Sur- 
gery in  King's  College. 


XXVIU  HONORARY    FELLOWS. 

ELECTED 

1886.  MacCormac,  Sir  William,  Bart.,  F.R.C.S.  England  and 
Ireland,  13  Harley  Street,  London,  W.  Surgeon  to  St. 
Thomas'  Hospital. 
1894.  Macewen,  William,  M.D,,  Mast.  Surg.,  3  Woodside  Cres- 
cent, Glasgow,  Scotland. 
*iS8o.  Moore,  Edward  Mott,  M.D.,  LL.D.,  74  South  Fitzhugh 
Street,  Rochester,  N.  Y.  Surgeon  to  St.  Mary's  Hospital. 
President,  1884. 

1894.  ScHEDE,  Prof.  Dr.,  Geh,  Med.  Rath.,  Director  of  Surgery, 
University  Clinic,  Bonn,  Germany. 

1882.  Smith,  Stephen,  A.M.,  M.D.,  LL.D.,  574  Madison  Avenue, 
New  York.  Professor  of  Clinical  Surgery  in  the  University 
Medical  College  of  New  York ;  Surgeon  to  the  Bellevue 
and  the  St.  Vincent's  Hospitals.     Vice-Presidetit,  1890. 

1896.  Terrier,  Dr.  Felix,  3  Rue  de  Copenhague,  Paris.  Professor 
of  Operative  Surgery  in  the  Faculty  of  Medicine  of  Paris ; 
Surgeon  to  the  Hopital  Bichat. 

*  Original  Fellow. 


ADDRESS   OF   THE   PRESIDENT. 

THE    RECENT    BUFFALO    INVESTIGATIONS    RE- 
GARDING  THE   NATURE   OF  CANCER. 


By  ROSWELL    park,  M.D., 

BUFFALO. 


At  the  risk  of  tedium  on  your  part  I  have^  ventured  to  select 
as  the  subject  of  my  address  to  you  a  topic  upon  which  I  have 
been  repeatedly  heard  during  the  past  few  years.  This  subject 
of  cancer  has  been  for  the  pathologist  the  mystery  of  ages,  and 
continues  to  be  the  subject  of  active  and  profound  study  in  all 
quarters  of  the  world,  with  now  a  promising  hope  of  solution. 
It  would  appear  to  be  about  the  only  local  disease  concerning 
which  there  is  still  much  of  the  uncertain  and  the  unknown. 
Diseases  like  scarlatina  and  syphilis,  for  instance,  for  which  we 
readily  acknowledge  acontagium  vivum,  are  wide-spread,  and  in 
no  sense  localized  among  the  tissues;  but  the  more  one  studies 
cancer  the  more  he  becomes  convinced  that  in  its  inception  it  is 
purely  local,  and  that  the  process  of  generalization  is  relatively 
slow,  save  in  certain  rare  instances.  The  older  views  about  the 
constitutional  nature  of  the  disease  then  may  be  set  aside  as 
absolutely  untenable,  and  we  have  nothing  left  to  do  now  except 
to  consider  it  in  its  thus  limited  relations. 

Pathologists  who  study  it  purely  from  the  dead-house  point 
of  view  have  confronted  some  of  the  greatest  problems  which  it 
has  to  offer,  but  have  also  missed  some  of  its  most  important 
aspects.  On  the  other  hand,  the  operating  surgeon,  who  sees 
in  this  mystery  only  the  question  of  how  far  he  may  go  with 
the  scalpel,  misses  also  the  fundamental  theories  of  its  origin 

Am  Surg  i 


2  PARK, 

and  the  consideration  of  its  etiology,  upon  which  its  whole  suc- 
cessful therapy  must  be  based.  Only  by  a  combination  of  ante- 
mortem  and  post-mortem  studies  can  its  nature  be  solved. 

Microscopical  sections  alone  may  well  arouse  the  numerous 
hypotheses  which  are  now  in  vogue  as  to  the  peculiar  behavior 
of  cells  and  their  reactions.  But  the  clinician  who  is  to  study 
the  disease  in  its  various  phases  may  well  criticise  every 
theory  which  ascribes  cancer  to  purely  intrinsic  causes,  even 
though  he  be  forced  to  acknowledge  that  he  can  not  abso- 
lutely demonstrate  an  extrinsic  cause.  Nevertheless,  so  much 
has  been  done  in  the  past  few  years  that  I  for  one  have  not 
hesitated  to  avow  myself  a  firm  believer  in  the  later  teaching  as 
to  the  infectious  nature  of  the  disease,  a  theory,  indeed,  which  I 
have  held  to  and  taught  for  nearly  fifteen  years. 

The  parasites  of  cancer,  be  their  nature  what  it  may,  are  in 
all  probability  polymorphic  in  extreme  degree,  and  masquerade 
under  many  forms,  changing  with  their  different  stages  of  repro- 
duction. So  much  of  the  personal  equation  enters  into  their 
consideration  and  investigation  that  one  must  know  an  indi- 
vidual and  his  methods  before  one  knows  exactly  what  estimate 
to  place  upon  his  work  and  the  weight  to  be  attached  to  his 
views.  Take  the  work,  for  instance,  of  Borrel.'  In  1892  he 
published  a  monograph  on  the  cellular  evolution  and  parasitism 
of  epithelioma,  in  which  he  claimed  that  for  four  years  he  had 
continuously  and  carefully  studied  the  subject,  and  convinced 
himself  that  there  was  no  doubt  about  the  parasitic  feature  of 
these  cases ;  he  claimed  priority  in  the  establishment  of  para- 
sitism for  Malassez.^  Borrel,  like  most  French  investigators,  is 
attached  firmly  to  the  parasitic  hypothesis,  and  is  of  the  belief 
that  the  parasites  in  question  are  protozoa — i.  e.,  are  of  animal 
origin.  In  the  plates  which  he  published  nine  years  ago  there 
may  be  seen  the  same  peculiar  appearances  which  most  other 
observers  since  his  time  have  noted.  In  this  connection  one 
may  say  that  the  most  striking  feature  of  all  these  studies,  as  one 
compares  the  plates  of  various  writers,  is  the  fact  that  they  all 

'   Evolution  Cellulaire  et  Parasitism  dans  rEpithelioma,  1892. 
^  Archiv.  de  Med.  Exp.,  1890,  2. 


ADDRESS    OF    THE    PRESIDENT.  3 

agree  as  to  the  extraneous  nature  of  certain  cells  which  they 
picture  in  various  stages  of  cell  division  or  reproduction,  though 
they  nearly  all  differ  in  the  peculiar  interpretation  of  those  phe- 
nomena which  they  illustrate,  differing  as  well  in  names  as  in 
classification  of  the  parasites,  differing  even  in  the  kingdom  to 
which  they  assign  them — i.  e.,  animal  or  vegetable.  It  is  most 
suggestive  in  one  regard,  though  somewhat  disturbing  in  an- 
other, to  see  practically  the  same  parasitic  forms  described  and 
figured  by  an  Italian  writer  as  showing  the  presence  of  blasto- 
mycetcX,  while  the  French  would  call  them  protozoa,  and  most 
of  the  German  scholars  would  indicate  them  as  mere  products 
of  cell  degeneration.  This  only  illustrates,  however,  that  to  a 
considerable  extent,  at  least,  the  differences  which  appear  so 
great  between  different  observers  are  merely  differences  of  in- 
terpretation. I  do  not  see  how  one  can  stucly  the  various  illus- 
trations of  this  subject,  still  less  the  actual  sections,  without 
being  firmly  of  the  opinion  that  parasitic  forms  are  certainly 
present,  although  he  be  absolutely  in  the  dark  as  to  their 
minute  nature,  just  as  no  man  can  come  long  in  contact  with 
the  clinical  features  of  the  disease  without  feeling  that  cancer 
must  be  considered  as  an  expression  of  infection  of  some  kind, 
without  necessarily  committing  himself  as  to  the  minute  nature 
of  the  infectious  element. 

Let  me  here  repeat  the  essential  feature  of  an  argument  which 
I  brought  before  this  Association  in  1898  with  regard  to  the 
infectious  nature  of  cancer.  I  have  found  that  the  length  of 
time  over  which  this  infection,  if  it  be  such,  may  extend,  as 
well  as  the  period  of  incubation,  are  in  many  cases  the  principal 
arguments  which  the  opponents  of  this  view  advance  against  its 
accuracy.  Such  argument  as  this,  however,  must  fail  from  what 
we  already  know  of  other  infections.  For  instance,  there  are 
infections  which  kill  within  a  few  hours  from  the  appearance  of 
their  first  lesions,  such,  for  instance,  as  bubonic  plague,  cholera, 
etc.  These  constitute  the  most  acute  and  disturbing  type  of 
their  kind.  The  time  limit  of  others  is  measured  by  days,  as, 
for  instance,  in  the  case  of  tetanus,  variola,  pneumonia,  and 
meningitis.     In  yet  others  the  course  of  the  disease  is  only  run 


4  PARK, 

within  a  few  weeks,  as  in  the  case  of  typhoid  fever.  Tubercu- 
losis and  actinomycosis,  again,  run  their  course  in  a  few  months, 
while  in  the  case  of  syphilis  and  leprosy  ordinarily  the  time  in 
which  they  kill  by  their  own  ravages  is  measured  only  in  years. 
No  violence,  then,  is  done  to  the  general  acceptance  of  the 
theory  of  infection  if  we  suppose  that  cancer  is  a  disease  whose 
duration  of  infection  may  extend  anywhere  from  weeks  to 
years. 

There  is  no  other  disease  which  is  characterized  by  metastasis 
in  which  the  pathologists  decline  to  see  evidences  of  parasitism. 
When  one  considers  the  more  acute  expressions  of  metastatic 
infection  which  he  may  see  in  surgical  and  puerperal  sepsis,  for 
example,  or  the  slower,  seen  especially  in  tuberculosis,  they  all 
convey  the  same  meaning  to  the  careful  student — i.  e.,  they  im- 
ply that  some  infectious  element  has  been  transported  from  one 
part  of  the  body  to  another,  there  to  set  up  disturbance  similar 
to  that  existing  at  the  point  of  departure.  Why  should  this  ex- 
planation be  so  acceptable  in  the  cases  of  all  other  diseases  and 
so  difficult  of  acceptance  in  the  case  of  cancer?  For  myself,  as 
I  have  often  remarked,  every  metastasis  of  cancer  has  the  form 
and  significance  of  an  inoculation  experiment  only  performed 
under  the  most  favorable  because  natural  conditions. 

The  primary  question  after  all  is  the  general  one  of  parasitism. 
Are  not  parasites  at  fault  ?  It  has  not  yet  been  reduced  to  a 
question  of  just  which  parasite.  However,  if  analogy  assists  one 
at  all,  he  must  not  forget  that  there  are  numerous  organisms 
which  may  produce  pus  formation,  and  these  belong  not  alone 
to  one  kingdom.  Why  then  may  it  not  be  so  with  cancer,  that 
not  one  organism  alone  but  perhaps  numerous  forms  are  at 
fault?  In  my  opinion  it  may  and  probably  will  be  found  that 
cancer  is  not  a  question  of  any  single  organism,  possibly  not 
even  of  a  single  class. 

Roger  Williams,  though  acknowledging  its  inoculability,  has 
very  little  faith  in  the  transmission  of  cancer  from  one  human 
being  to  another,  even  by  contact,  and  he  quotes  Demarquay, 
who  collected  134  cases  of  cancer  of  the  penis,  whereas  in  only 
one  instance  was  the  wife  affected  with  uterine  cancer. 


ADDRESS    OF    THE    PRESIDENT.  5 

With  regard  to  its  inoculability,  he  acknowledges  that  the 
evidence  is  so  weighty  as  to  be  practically  conclusive.  Aside 
from  instances  to  which  I  have  already  alluded  in  other  papers, 
I  quote,  e.  g.,  the  following  :  "  Cripps  has  reported  the  case  of  a 
woman  with  extensive  cancerous  ulceration  of  the  left  mammary 
region,  who,  being  unable  to  wear  any  dress,  had  kept  her  arm 
bent  at  a  right  angle  and  in  constant  contact  with  the  disease 
for  several  months,  in  consequence  of  which  the  skin  in  the 
vicinity  of  the  elbow  became  the  seat  of  a  cancerous  ulcer  sev- 
eral inches  in  diameter."  A  similar  instance  has  been  already 
reported  by  De  Morgan.  Instances  of  the  spread  of  disease  by 
contact  infection  from  the  uterus  to  the  vagina  have  been  re- 
ported by  Thorn  and  many  others.  Thorn's  case  was  a  woman, 
aged  forty-six  years,  whose  uterus  had  been  deflected  to  the 
right  and  retained  by  adhesions.  Owing  to  this  bad  position, 
the  cancerous  excrescence  was  constantly  in  contact  with  the 
left  side  of  the  vagina,  where  another  cancer  developed  which 
fitted  that  on  the  cervix  "  like  a  saucepan  lid."  Elsewhere  the 
vagina  was  free  from  disease.  Numerous  cases  are  on  record 
where  the  primary  outbreak  of  the  disease  in  the  fundus  has 
been  followed  by  similar  lesions  of  the  cervix.  The  cases  in 
which  cancer  of  the  upper  alimentary  tract  has  been  followed 
by  others  lower  down  are  common,  and  Moxon  has  described 
the  spread  of  the  disease  along  the  trachea  to  the  lungs  in  a 
similar  way.  Cancer  in  the  pelvis  is  often  apparently  due  to 
infection  with  nodules  detached  from  cancerous  growths  in  the 
upper  part  of  the  abdomen,  while  visceral  cancer  projecting  into 
the  peritoneal  cavity  often  infects  the  exposed  tissue  with  which 
it  comes  in  contact.  Numerous  cases  are  now  on  record  of 
cancer  along  the  track  of  the  trocar  used  in  tapping  for  ascites 
due  to  cancerous  disease.  Surgeons  now  quite  generally  admit 
this  traumatic  dissemination  of  the  disease  by  inoculation  of 
wounds  during  operations.  Schopf  reports  cancerous  infection 
of  the  lateral  incisions  into  the  vagina  and  vulva  necessitated 
in  the  course  of  vaginal  hysterectomy  for  cancer. 

Roger  Williams  closes  his  section  on  this  subject  by  repeating 
the  warning  now  so  often  given  that  care  should  be  taken  to 


O  PARK, 

avoid  cutting  into  the  malignant  neoplasms  during  their  re- 
moval, for  "  such  is  the  great  tenacity  of  life  and  the  wonderful 
proliferative  power  of  even  the  most  diminutive  fragments  of 
cancer  that  when  left  behind  they  only  too  often  constitute 
fresh  centres  of  disease."  If  this  is  not  a  virtual  admission  of 
the  infectious  nature  of  the  disease  by  one  of  its  strongest 
opponents  I  scarcely  know  how  to  regard  it. 

It  will  probably  not  be  amiss  now  if  I  ask  your  attention  to 
some  recent  work  which  has  been  done  in  the  State  Laboratory, 
conducted  under  the  auspices  of  the  University  of  Buffalo.  We 
have  enjoyed  exceptional  facilities  in  that  laboratory  for  the 
study  of  cancer,  it  having  been  founded  for  the  purpose,  and 
generously  maintained  and  supported  by  the  State.  Some 
years  ago  I  outlined  in  a  paper  which  partially  treated  of  this 
subject  the  general  lines  of  investigation  which  I  thought  it 
would  be  necessary  to  follow  in  order  to  arrive  at  more  accu- 
rate notions  regarding  the  nature  of  cancer.  These  included 
not  only  the  ordinary  histological  and  bacteriological  methods 
of  investigation,  but  I  also  at  that  time  insisted  that  the  subject 
should  be  studied  from  a  biological  and  from  a  chemical  stand- 
point. The  latter  method  had  never  been  undertaken  in  any 
systematic  way  until  we  began  it  in  this  laboratory,  where  we 
have  now  a  competent  biological  chemist,  and  are  at  last  able 
to  study  the  disease  in  some  of  those  relations  which  have  been 
hitherto  either  misunderstood  or  not  understood  at  all.  The 
studies  already  made  have  seemed  to  make  it  clear  that  death 
in  cases  of  cancer  comes  about,  as  in  so  many  other  diseases, 
by  a  sort  of  terminal  infection,  which  is  a  conspicuous  feature 
of  the  disease,  and  has  not  hitherto  attracted  sufficient  attention. 
It  appears  to  us  as  though  the  end  is  finally  brought  about  by 
a  distinct  toxivmia,  and  particularly  by  a  sort  of  hrematogenous 
infection.  This  has  been  made  more  clear  by  a  study  of  the 
experimental  side  than  by  the  clinical  side  of  the  disease.  In 
all  our  animals  inoculated  and  injected  this  feature  has  become 
so  very  distinct  as  to  be  positively  striking.  The  exact  nature 
of  these  terminal  changes  has  not  yet  been  made  out  beyond 
what  is  implied  in  the  term  "  hii;matogenous."     Moreover,  as 


ADDRESS    OF    THE    PRESIDENT.  J 

I  have  previously  indicated  in  another  paper,  the  cachexia  which 
is  so  pronounced  a  clinical  feature  of  cases  of  cancer  is  produced 
by  varied  and  varying  causes,  and  it  is  hard  to  ascribe  to  the  dis- 
tinct toxjemia  of  this  disease  its  proper  role.  Much  more  can 
be  learned  about  the  disease  by  experimental  research  than  by 
speculation  concerning  clinical  features. 

In  a  paper  which  I  presented  to  this  Association  in  1898  I 
argued  at  some  length  for  the  infectious  or  parasitic  nature  of 
this  disease.  At  that  time  I  had  just  returned  from  Italy,  and 
was  particularly  conversant  with  the  work  done  by  the  Italian 
investigators,  who  seemed  to  be  almost  unanimous  in  belief  as 
to  the  vegetable — /.  e.,  fungous — nature  of  these  parasites.  If  in 
the  succeeding  years  views  regarding  their  nature  have  gradu- 
ally changed,  it  may  be  but  a  natural  outcome  of  further  ac- 
quaintance with  the  bodies  in  question  and  a  more  complete 
recognition  of  their  extraordinary  polymorphism,  as  well  as  our 
ignorance  regarding  the  protozoa,  especially  regarding  their 
life  histories.  The  predictions  of  the  Italians  have  failed  in 
many  respects,  and  it  is  by  no  means  so  easy  to  successfully 
inoculate  animals  with  the  yeast  as  had  been  generally  sup- 
posed, but  the  differences  that  have  come  about  in  our  own 
views  in  Buffalo  have  been  essentially  the  outcome  of  our 
own  experimental  work.  Perhaps  I  can  best  illustrate  this  by 
epitomizing  some  of  the  work  as  recently  reported  by  my  col- 
league. Dr.  Gaylord,  who  really  has  directed  it,  and  is  entitled 
to  the  credit  of  it. 

In  August,  1898,  I  explored  the  abdomen  of  a  patient,  the 
case  being  one  in  which  a  clear  diagnosis  of  intra-abdominal 
carcinoma  could  be  made,  but  beyond  that  no  accurate  con- 
clusions reached,  because  of  the  distention  by  ascitic  accumula- 
tion. The  fluid  from  the  patient's  abdomen  was  collected  in 
abundance,  and  it  was  in  this  fluid  that  the  bodies  which  have 
since  so  attracted  attention  were  by  us  first  observed.  Ana- 
tomically the  case  eventually  proved  to  be  one  of  adenocarci- 
noma, probably  arising  from  the  appendix,  spreading,  involving 
the  greater  portion  of  the  peritoneal  surface  of  the  omentum  and 
mesentery,  and  then  undergoing  mucoid  degeneration  to  such 


8  PARK, 

an  extent  that  when  the  abdomen  was  opened  at  the  operation 
simply  a  mass  of  soft  cancerous  contents  was  exposed.  The 
fluid,  which  was  removed  through  a  sterile  tube,  and  remained 
bacteriologically  sterile  at  the  end  of  two  weeks,  contained  a 
large  number  of  small  hyaline  bodies,  which,  under  the  micro- 
scope, were  seen  to  change  in  size  and  form  and  to  pass 
through  a  cycle  of  development  up  to  what  appeared  to  be  a 
spore-forming  stage.  These  bodies  were  first  mistaken  for  fat 
droplets,  but  did  not  react  to  ether  or  osmic  acid,  as  fat  usually 
does.  They  were  injected  into  animals.  Those  which  received  in- 
jection into  the  peritoneal  cavity  developed  no  tumor  formation, 
but  marked  peritonitis  and  enlargement  of  local  lymph  nodes. 
In  their  peritoneal  fluid  the  same  characteristic  spherical  nucle- 
ated bodies,  or  sacs  filled  with  granules,  were  found.  When 
these  bodies  were  kept  a  few  days  in  a  thermostat  they  not  only 
changed  their  form,  but  apparently  developed  into  larger  struc- 
tures, in  many  of  which  pseudopodia  were  seen.  In  one  slide 
at  least  twenty  such  organisms  were  arranged  around  an  air- 
bubble,  all  of  them  with  long  pseudopodial  projections,  as 
though  by  some  chemotactic  excitation.  Another  animal  whose 
jugular  had  been  injected  was  found  fifty  days  after  injection 
with  white  nodules  in  the  lungs,  which,  on  microscopical  exam- 
ination, proved  to  be  minute  adenocarcinomata.  The  tumor 
cells,  as  well  as  cells  from  enlarged  follicles  found  in  the  spleen, 
were  found  to  contain  adventitious  bodies  of  unusual  appear- 
ance. Those  of  the  splenic  pulp  corresponded  to  Russell's 
fuchsin  bodies,  while  in  the  perivascular  spaces  Plimmer's 
bodies — i.  e.,  half-grown  organisms — were  found  in  large  num- 
bers, just  as  he  has  found  them  in  carcinoma  in  man. 

Attempts  to  cultivate  these  organisms  at  the  time  were  not 
successful,  but  success  was  met  with  later,  the  culture  medium 
giving  the  best  results  being  that  recommended  by  Celli  for  the 
cultivation  of  amoeba — z".  ^.,a  bouillon  made  with  fucus  crispus. 
Other  animals  inoculated  at  this  time  also  developed  evidences 
of  peritonitis,  splenic  enlargemeut,  and  pulmonary  oedema.  In 
their  peritoneal  fluid,  as  well  as  blood,  and  in  the  organs,  large 
numbers  of  these  parasites  were  detected,  while  sections  since 


ADDRESS    OF    THE    PRESIDENT.  9 

stained  by  Plimmer's  method  revealed  the  presence  of  numer- 
ous parasites  in  all  of  the  viscera,  especially  in  the  lymphatics. 

As  an  outcome  of  the  experiments  we  were  especially  directed 
toward  investigation  of  fresh  scrapings  from  cancer.  Starting 
with  the  assumption  that  the  small  spherical  bodies  which  so 
closely  resembled  fat  are  not  fat.  Dr.  Gaylord  endeavored  to 
determine  how  the  great  discrepancy  between  the  large  number 
of  parasites  found  in  fresh  cancer  and  the  small  number  in  sections 
could  be  accounted  for.  Moreover,  examination  of  numerous 
tumors  shows  that  in  all  rapidly  growing  tumors  a  great  num- 
ber of  organisms  are  present.  Comparing  tumors  removed  by 
operation  with  those  removed  post-mortem,  it  became  evident 
that  the  organisms  either  increase  rapidly  during  the  period  just 
before  death  or  that  they  proliferate  in  the  tissue  immediately 
after  death.  In  two  cases  of  large  tumors  examined  immediately 
after  operation,  and  found  to  contain  numerous  organisms  which 
yet  remained  sterile  to  ordinary  methods,  the  following  obser- 
vations were  made  :  Repeated  examinations  of  successive  scrap- 
ings made  at  intervals  of  several  hours  showed  that  the  relative 
size  of  the  organisms  increased.  In  the  course  of  ten  hours 
repeated  scrapings  showed  that  amoeboid  forms  were  greatly 
increased  in  number,  and  that  after  twenty-four  hours  the  "  mo- 
rula," or  spore-bearing  stage,  had  been  reached.  At  the  end  of 
three  days  the  spore-sacs  were  completely  replaced  by  groups 
of  hyaline  bodies  considerably  larger  than  those  which  the  sacs 
originally  contained.  From  this  it  would  appear  that  the  so- 
called  fatty  degeneration  of  carcinoma  cells  is  at  least  in  some 
part  due  to  the  presence  of  organisms  which  have  been  mis- 
taken for  fat  droplets  or  for  epithelial  cells  in  advanced  fatty 
degeneration. 

It  was  also  possible  to  determine  that  cancer  juices  (or  so- 
called  cancer  milk  of  some  of  the  older  writers)  consist  almost 
entirely  of  pure  cultures  of  these  organisms  ;  also  that  fluid  from 
malignant  ovarian  cysts  contains  them  in  large  numbers,  as  does 
also  the  peculiarly  characteristic  soft  mass  found  in  the  cavities 
of  certain  adenocarcinomata  of  the  ovaries.  Thus  in  practically 
all  scrapings  from  cancer  could  be  seen  either  small  hyaline 


lO  PARK, 

refractive  forms,  which  in  suspension  possess  a  characteristic 
oscillating  motion,  or  larger  forms  with  projecting  pseudopo- 
dia,  or  saccular  forms  containing  very  refractive  spherical  bodies. 
By  incubating  hanging-drop  preparations  of  fresh  scrapings 
from  cancer  the  smaller  forms  can  be  followed  in  their  de- 
velopment as  they  increase  in  size,  and  if  kept  upon  a  warm 
stage  they  may  be  seen  to  throw  out  especially  developed 
nuclei,  and  conclude  their  life  history  by  a  formation  of  a  sac 
in  which  they  develop  their  spores.  Since  the  specific  gravity 
of  these  organisms  is  less  than  that  of  water  they  rise  to  the 
surface  in  the  hanging-drop,  and  are  to  be  sought  directly  be- 
neath the  cover-slip,  and  not  in  the  lower  portion  of  the  fluid. 

Having  learned  the  nature  of  these  changes  in  the  hanging- 
drop  outside  the  body,  it  became  necessary  next  to  determine 
why  they  could  not  be  more  easily  demonstrated  in  the  tissues 
by  ordinary  staining  methods.  It  was  then  found  that  nearly 
all  the  fixatives  in  common  use  cause  the  disappearance  of  all 
the  spore-sacs  and  the  greater  part  of  the  more  developed  or- 
ganisms. Only  two  small,  more  resistant  forms  remained,  and 
these  would  take  the  ordinary  aniline  stains.  These  now  appear 
to  be  those  forms  seen  so  long  ago  by  Russell  and  so  generally 
known  by  his  name.  A  little  later  in  their  life-history  these 
reach  such  a  stage  of  development  and  size  that  it  is  often  im- 
possible to  state  whether  they  are  parasites  or  tissue  elements. 
In  one  case,  however,  of  carcinoma  of  the  bladder,  where  these 
organisms  appeared  in  large  numbers  in  the  urine,  Gaylord  was 
able  to  detect  these  forms  between  epithelial  cells  and  attached 
to  the  surface  of  the  tumor  after  its  removal. 

Another  experience  encountered  in  the  summer  of  1898  made 
a  profound  impression  upon  our  minds.  An  autopsy  was  made 
upon  a  patient  who  had  died  of  carcinoma  of  the  uterus.  It 
disclosed  advanced  general  peritonitis  with  abundance  of  fluid, 
such  as  would  ordinarily  be  produced  by  perforation  and  ex- 
tension. It  was  found,  however,  that  there  was  absolutely  no 
perforation,  and  the  peritonitis  seemed  to  be  due  to  a  general 
infection  whose  source  was  to  be  traced.  Further  preparation 
was  made  by  Gaylord  from  the  surface  of  the  peritoneum,  the 


ADDRESS    OF    THE    PRESIDENT.  II 

spleen,  the  lungs,  and  the  blood,  showing  large  masses  of  pale 
hyaline  forms  seen  so  often  in  fresh  scrapings,  in  the  peritoneal 
fluid  of  cancer,  and  in  the  blood  and  fluids  of  experimental 
animals. 

In  January,  1899,  before  the  Medical  Society  of  the  State  of 
New  York,  Dr.  Gaylord  and  myself  both  stated  that  we  be- 
lieved he  had  recognized  and  demonstrated  the  presence  of 
parasites  in  cancer  and  had  successfully  reproduced  cancer  in 
animals,  but  that  we  were  at  that  time  not  in  a  position  to 
state  positively  the  nature  of  these  parasites.  Since  that  time 
most  elaborate  studies  have  been  made,  both  of  experimental 
animals  and  by  post-mortem  examination  of  patients  dying  of 
cancer,  and  Dr.  Gaylord  is  now  able  to  demonstrate  that  all  the 
organs  of  cases  dying  of  cancer,  including  sarcoma  and  epithe- 
lioma, also  the  blood,  contain  large  numbers  of  the  Organisms. 

What  shall  be  said  with  regard  to  the  yeasts  and  the  fungi 
which  numerous  observers,  especially  among  the  Italians,  be- 
lieve to  be  the  actual  parasites  of  cancer  ?  It  certainly  is  true 
that  Sanfelice  has  produced  neoplasms,  essentially  tumors,  in 
animals,  by  inoculation  with  the  yeasts  which  he  cultivated; 
but  this  occurred  only  in  isolated  instances,  and  can  be  regarded 
as  proving  only  that  the  yeasts  are  pathogenic,  but  not  certain 
cancer  producers.  That  fact  had  already  been  made  plain  by 
Busse,  independently  of  the  Italian  observers.  The  yeasts  cer- 
tainly have  their  pathogenic  role,  and  are  now  known  to  pro- 
duce certain  skin  lesions  as  well  as  to  be  associated  with 
certain  internal  diseases,  and  occasionally  with  the  forma- 
tion of  pus.  Nothing  has  yet  been  established  to  prove  that 
they  may  not  in  occasional  instances  produce  cancer,  but  so 
far  at  least  as  our  Buffalo  researches  are  concerned  we  have 
to  report  that  the  Italian  observations  have  been  neither  abso- 
lutely disproven  nor  confirmed.  Sanfelice  was  unable  to  culti- 
vate the  organisms  from  the  region  of  inoculation,  but  was  in 
many  instances  able  to  regain  them  from  the  regional  lymph 
nodes.  By  transferring  these  from  animal  to  animal  he  en- 
hanced their  virulence  to  such  an  extent  that  they  became  fatal 
to  the  animals  in  which  they  were  injected. 


12  PARK, 

Further  difficulty  is  added  to  this  line  of  investigation  by  the 
extraordinary  polymorphism  of  many  of  these  minute  organ- 
isms. Even  the  yeasts  and  fungi  undergo  numerous  changes  in 
size,  and  doubtless  this  is  true  to  greater  extent  of  the  protozoa. 

Plimmer,  of  London,  has  rendered  most  signal  service  in  this 
direction  by  his  extraordinary  patience  and  the  number  of  his 
investigations.  During  a  period  of  six  years  he  examined  micro- 
scopically 1278  carcinomata.  In  11 30  of  these  cases  he  found 
those  parasitic  bodies  which  are  now  associated  with  his  name. 
They  were  found  in  all  portions  of  the  cancer,  but  especially  at 
the  growing  edges.  They  appear  only  in  the  active  cells  and 
not  in  those  which  are  undergoing  degeneration.  They  appear 
also  between  the  cells,  and  even  in  the  leucocytes.  In  the  more 
rapidly  growing  tumors  they  are  found  in  large  number.  He 
has  found  even  as  many  as  sixty  in  one  cell.  Comparing  sec- 
tions of  cancer  with  those  of  other  growths,  granulomata,  etc., 
as  well  as  normal  tissues,  he  stated  positively  that  he  had  never 
seen  in  any  instance,  save  in  cancer,  bodies  which  resemble 
these  parasitic  forms  or  which  have  their  reactions.  The  claims 
made  by  Plimmer  have  been  almost  faithfully  corroborated  by 
work  done  in  the  Buffalo  Laboratory,  and  substantiate  his  claim 
that  these  bodies  are  present  in  practically  all  carcinomata. 
They  may  be  demonstrated  in  the  fresh  state,  although  here  it 
is  somewhat  difficult  to  differentiate  them  from  the  fat  droplets 
which  they  resemble.  The  most  minute  forms  might  be  con- 
fused with  cocci.  The  maturer  forms  appear  either  as  spherical 
bodies  with  delicate  outlines,  or  in  full  form,  as  well  within  as 
without  the  cells.  Sometimes  pseudopodia  may  be  seen,  in 
which  case  their  contained  granules  remain  for  the  most  part 
in  the  larger  portions  of  the  structure.  Sometimes  the  extra- 
cellular bodies  may  be  observed  to  change  their  form  by 
placing  them  in  a  thermostat.  Summing  up  these  investigations 
of  Plimmer's  bodies,  it  may  be  stated  that  they  present  character- 
istic appearances,  and  can  be  differentiated  from  cell-degenera- 
tions of  the  usual  type  as  well  as  from  other  structures  which 
they  may  resemble.  It  has  never  been  possible  to  make  out 
degenerative  changes  in  the  epithelial  or  other  cells  in  cases  of 


ADDRESS    OF    THE     PRESIDENT.  I3 

cancer  which  can  really  be  confused  with  the  so-called  Plim- 
mer's  bodies. 

It  is  extremely  probable  that  most,  if  not  all,  of  the  observers 
who  have  described  and  figured  cell  inclusions  have  been  watch- 
ing the  typical  Plimmer's  bodies.  This  is  particularly  true  of 
Sjobring. 

Culture  experiments  made  in  our  laboratory  by  the  ordinary 
bacteriological  methods  have  been  uniformly  negative  in  result. 
In  order  to  show  that  they  have  been  assiduously  tried,  I  would 
say  that  sixty-four  different  media,  including  about  everything 
that  has  ever  been  suggested  and  some  original  formulfe  have 
been  employed,  and  of  various  degrees  of  acidity  and  alkalinity. 
Per  co7itra,  the  organisms  have  been  usually  obtained  by  culti- 
vation after  experimental  inoculation  in  animals.  In  those 
instances  in  which  yeasts  were  employed, it  has  been  possible 
to  produce  a  pretty  typical  blastomycetic  mycosis  with  abscess 
formation  or  characteristic  infectious  granuloma. 

Matters  rested  in  this  state  in  our  laboratory  for  two  years, 
our  staff,  and  especially  Dr.  Gaylord,  varying  in  opinion  as  the 
evidence  seemed  to  present  itself  one  way  or  the  other,  inclin- 
ing at  times  to  the  view  that  parasites  were  fungi  and  at  other 
times  that  they  were  protozoa,  the  difficulties  of  the  research 
being  such  that  it  seemed  most  difficult  to  weigh  the  evidence 
and  reach  a  satisfactory  conclusion.  This  was,  however,  at  last 
and  recently  hastened  by  the  investigations  of  Copeman  and 
Funk  on  the  protozoa  of  vaccine  lymph.  Section  of  rabbit 
cornea  which  had  been  inoculated  with  vaccine  virus  showed 
not  only  that  the  half-grown  formation  of  the  vaccine  organ- 
ism is  closely  related  in  appearance  to  Plimmer's  and  Russell's 
bodies,  but  that  the  life-cycle  of  this  organism  seemed  to  epit- 
omize that  of  the  cancer  parasites  which  we  had  been  studying. 
Going  over  the  old  work  which  had  been  done  by  methods 
previously  in  use,  in  the  light  of  these  latest  researches  on  vac- 
cine organisms,  very  positive  conclusions  can  now  be  reached. 

It  would  appear,  for  instance,  that  the  protozoa  are  capable 
of  producing  in  man  (as  Pfeiffer  showed  that  they  might  pro- 
duce both  in  man  and  in  animals)  lesions  of  widely  different 


14  PARK, 

nature  from  mere  infection  of  epithelium.  For  instance,  in  a 
pustule  found  upon  the  surface  of  a  cancerous  breast  which  I 
removed  in  February  of  this  year,  Dr.  Gaylord  found  a  quantity 
of  material,  consisting  of  leucocytes,  red  corpuscles,  and  a  very 
large  number  of  cells  which  proved  to  be  protozoa.  On  cutting 
into  the  breast  and  making  fresh  scrapings,  these  were  found 
to  consist  of  closely  packed  epithelial  cells,  fat  droplets,  and  a 
considerable  number  of  small  greenish  hyaline  bodies  of  high 
refractive  index,  and  corresponding  in  every  way  to  the  Plim- 
mer's  bodies  and  to  the  parasites  already  described.  Sections 
stained  in  the  ordinary  way,  as  well  as  by  Plimmer's  method, 
show  also  the  same  condition.  Sections  of  the  region  of  the 
pustule  above  mentioned  show  a  tremendous  number  of  spher- 
ical and  oval  Russell  bodies  as  well  as  large  cells  with  more 
than  one  nuclei,  many  of  them  containing  spherical  bodies  like 
Russell's.  This  pustule  would  appear  to  have  been  the  result 
of  an  embolic  deposit  of  parasites  from  the  cancer  itself,  and  we 
naturally  interpreted  it  as  indicating  that  the  organisms  of  can- 
cer are  capable  of  producing  other  lesions  than  mere  epithelial 
infection. 

In  a  short  time  full  report  will  be  made  of  the  results  of 
inoculation  of  seventy-two  animals.  The  material  with  which 
they  were  inoculated  consisted  of  peritoneal  fluid,  fluid  from 
the  interior  of  malignant  ovarian  cysts,  bacteriologically  sterile 
cancer  and  dried  cancerous  lymph  nodes  rubbed  up  with  salt 
solution.  Some  of  the  latter  contained  metastatic  cancerous 
deposits,  while  in  a  number  Russell's  bodies  were  detected. 
In  each  case  the  fresh  material  was  carefully  examined  and  the 
presence  of  parasites  determined  before  inoculation. 

Briefly  epitomizing  the  results  obtained,  we  have  the  following 
interesting  features  :  Fourteen  guinea-pigs  inoculated  in  the  peri- 
toneum with  peritoneal  fluid  containing  the  organism  had  an 
average  life  of  fifty-eight  days  ;  four  inoculated  in  the  peritoneum 
with  cancer  mush,  an  average  length  of  fifty-eight  days;  eleven 
inoculated  in  the  peritoneum  with  dry  cancerous  lymph  nodes, 
forty-five  days  ;  while  six  guinea-pigs  inoculated  with  material 
from  these  animals  already  infected  gave  an  average  length  of 


ADDRESS    OF    THE    PRESIDENT.  I5 

life  of  twenty-nine  days — but  little  more  than  half  the  length 
of  time  for  the  animals  inoculated  directly  from  man.  Only 
one  interpretation  can  be  put  upon  this,  and  that  is  the  increased 
virulence  obtained  by  passing  the  organism  through  even  one 
animal.  By  other  experiments,  organisms  grown  in  a  collodion 
sac  within  the  peritoneal  cavity  of  rabbits  were  so  enhanced  in 
virulence  that  a  healthy  rabbit  inoculated  in  the  ear  vein  died 
within  fifteen  days  of  general  haematogenous  infection.  Thus 
it  will  be  seen  that  animals  are  rapidly  infected  when  inoculated 
with  cancerous  material  proven  to  be  bacteriologically  sterile, 
and  consisting  essentially  of  pure  culture  of  the  cancer  parasites. 
All  these  animals  rapidly  emaciated,  and  presented,  on  opening 
the  abdominal  cavity,  enlarged  peritoneal  lymph  nodes,  an  in- 
crease in  fluid,  and  enlargement  of  the  spleen.  Several  of  the 
animals  presented  also  minute  nodules  in  the  lungs,  which  we 
are  quite  justified  in  interpreting  as  beginning  adenocarci- 
noma, while  similar  nodules  were  noticed  in  other  instances  in 
the  liver  and  spleen.  In  all  of  the  organs  thus  far  examined  by 
Plimmer's  method  large  numbers  of  parasites  were  found  in 
various  stages  of  development.  The  lungs  in  all  instances  show 
that  the  parasites  have  penetrated  the  bronchial  epithelium,  caus- 
ing a  typical  proliferation  and  epithelial  nests  beneath  the  base- 
ment membrane,  practically  such  lesions  as  Pfeiffer  described  ten 
years  or  more  ago  in  many  of  the  lower  forms  of  animal  life. 

The  mention  of  protozoa  as  active  agents  in  the  production 
of  cancer  will  strike  no  one  as  a  novelty.  The  lowest  forms  of 
animal  unicellular  life  have  been  regarded,  as  it  were,  as  disease- 
producing  agents  for  a  number  of  years.  Among  the  most 
conspicuous  investigators  of  this  subject  has  been  L.  Pfeififer,  of 
Weimar,  who  has  published  monographs  at  various  times  on 
this  special  subject.  Published  as  they  were,  they  seem  to  have 
attracted  less  attention  than  they  deserve  or  would  if  they  had 
been  printed  in  some  journals  of  wide  circulation.  So  early  as 
1890  Pfeififer  had  written  and  studied  most  extensively  on  this 
subject,  and  his  investigations  are  remarkable  examples  of  the 
fidelity  and  patience  with  which  some  of  the  Continental  inves- 
tigators pursue  such  studies. 


l6  PARK, 

Then  we  have  had  recent  descriptions  of  Eisen's  cancriamoeba, 
showing  that  so  far  as  the  microscope  alone  could  take  him  he 
was  working  in  the  right  direction.  There  is  also,  for  instance, 
Korotnefif's^  rhopalocephalus  carcinomatosus,  which  he  has 
figured  and  described  with  infinite  pains.  There  are,  further, 
Bosc's  description  and  plates  of  myxosporidia,  coccidia,  etc., 
which  present  very  similar  appearances.  But  the  most  elabor- 
ate monographs  of  all  dealing  with  this  side  of  the  subject  are 
those  of  Pfeiffer."  He  attacks  the  matter  from  the  comparative 
stand-point,  which  is  by  far  the  most  successful  one,  and  shows, 
for  instance,  how  epithelial  proliferation  is  provoked  in  the  lower 
forms  of  life  and  by  many  parasitic  forms  belonging  to  the  pro- 
tozoa. Thus  clepsidriana  will  produce  in  the  intestine  of  the 
golden  beetle  (chrysomela)  and  the  horned  beetle  (carabus)  epi- 
thelial proliferation  by  which  a  heaping  up  of  cells  and  almost 
miniature  tumor  formation  are  produced.  This  is  particularly 
true  in  the  case  of  the  intestinal  lesions  produced  in  the  beetle 
by  actinocephalus.  Tumor  formation  in  the  spermatoblastic  cells 
of  the  earthworm  is  produced  by  certain  of  the  momocystidia, 
while  klossia  produces  a  similar  effect  in  the  kidney  tissue  of 
certain  snails.  Coccidiosis  is  now  well  known,  especially  in  the 
rabbit  and  the  domestic  mouse,  as  the  explanation  of  certain 
neoplastic  lesions.  Infection  by  certain  sporidia  produces  gen- 
eral muscle  tumors  in  the  hog,  sheep,  horse,  and  other  animals. 
The  name  myositis  gregarinosa  is  given  to  certain  muscle- 
tumors  caused  in  the  horse  by  sarcosporidia,  and  to  tumors  in 
the  oesophagus  and  pleura  of  sheep  produced  by  similar  organ- 
isms. Pfeiffer  found  also  muscle-tumors  produced  in  pickerel 
and  other  fish  by  myxosporidia,  as  well  as  tumors  of  various 
viscera,  and  even  the  heart  substance.  These  parasites  also 
produce  neoplasms  in  nerve-trunks,  thus  leading  to  lesions 
which  he  describes  as  polyneuritis  parasitica.  They  also  pro- 
duce tumors  in  the  swimming  bladders  of  the  horse-mackerel 


'  Sporozoen  als  Krankheitserreger. 

-  Die  Zell-Erkrankung  und  die  Geschwulstbildung  durch  Sporozoen,  and  Die  Protozoen 
als  Krankheitserreger. 


ADDRESS    OF    THE    PRESIDENT.  1/ 

(caranx),  which  he  considers  expressions  of  endothelial  infec- 
tious tumors. 

A  close  study  of  these  comparative  lesions  and  of  tumor 
formations  in  human  beings  leads  Pfeiffer'  to  say:  "When  the 
cancer  parasite  is  an  obligate  cell,  parasite  cultivation,  accord- 
ing to  the  ordinary  bacteriological  methods,  cannot  succeed,  or, 
if  at  all,  probably  only  in  the  hen's  egg  as  a  medium." 

Having  thus  called  your  attention  to  some  of  his  researches 
upon  the  role  which  the  protozoa  play  in  comparative  pathol- 
ogy, let  me  remind  you  of  what  he  has  done  and  found  con- 
cerning their  activity  as  disease-producing  agents  among  human 
beings.  The  dermatologists  meet  frequently  with  a  disease 
which  we  call  molluscum  contagiosum.  A  similar  lesion  is 
met  with  also  in  birds,  and  especially  among  domestic  fowls, 
pigeons,  etc.,  and  is  seen  upon  the  head,  neck,  eyelids,  inner 
surface  of  the  thighs,  and  about  the  anus.  In  birds  it  seems 
often  to  be  accompanied  with  a  formation  of  false  membrane 
upon  mucous  surfaces,  giving  rise  to  the  term  avian  diphtheria. 
This,  however,  is  a  most  unfortunate  expression,  since  it  has 
nothing  whatever  to  do  with  our  diphtheria.  In  human  beings 
similar  tumors  appear  on  all  parts  of  the  human  body  and  seem 
to  possess  a  certain  degree  of  contagiousness  or  infectiousness. 
Thirty  years  ago  Virchow  called  attention  to  the  resemblance 
between  the  so-called  molluscum  bodies  and  certain  protozoa 
found  in  the  intestine  and  liver  of  rabbits.  In  1873,  Bollinger 
called  attention  also  to  the  resemblances  between  these  new 
formations  and  what  was  known  as  bird-pox.  He  it  was  who 
first  gave  it  the  name  of  epithelioma  contagiosum.  In  1890, 
Pfeiffer  fully  described  the  peculiar  infection  of  the  epithelial  cells 
by  protozoa,  and  figured  characteristic  appearances  in  his  book. 
He  also  showed,  as  have  Barrier  and  Wickham,  the  protozoan 
nature  of  Paget's  disease  of  the  nipple,  agreeing  with  these 
other  authors  as  to  the  nature  of  the  disease,  and  illustrating 
the  gradual  invasion  of  the  milk-ducts  by  these  parasites. 

Pfeififer  also   called    attention    to   the   changes   occurring  in 

•  Die  Zell-Erkrankung  und  die  Geschwulstbildung  durch  Sporozoen,  and  Die  Proto- 
zoan als  Krankheitserreger,  p.  97. 

Am  Surg  2 


l8  PARK, 

epithelial  cells  in  herpes  zoster  and  the  eruptive  diseases  of 
children.  He  showed  how,  in  a  fresh  herpetic  vesicle,  the 
epithelium  could  be  found  packed  with  protozoa,  and  how  the 
latter  could  also  be  seen  in  the  fluid  and  in  the  tissues.  Similar 
vesicles  produced  by  burning,  by  croton  oil,  etc.,  did  not  show 
these  evidences  of  parasitic  infection.  This  is  of  practical  in- 
terest in  connection  with  some  of  the  herpetic  eruptions  seen 
along  with  cases  of  cancer.  In  a  later  monograph  published  in 
1895,  Pfeiffer  claimed  to  be  among  the  first  who  had  determined 
the  animal  nature  of  certain  parasites  seen  in  tumors,  and  espe- 
cially in  carcinoma  and  sarcoma.  He  did  not  claim  to  have 
succeeded  with  inoculation  experiments,  but  was  sure  of  the 
microscopical  appearances.  In  this  publication  he  gave  numer- 
ous illustrations  of  the  parasites  in  the  epithelial  cells,  which, 
save  for  a  certain  coarseness  of  drawing,  would  pass  muster 
to-day.  He  shows,  for  instance,  the  parasitic  infection  of 
muscle  cells,  and  even  their  nuclei,  with  zooglcea  spores,  and  it  is 
impossible  to  examine  his  brochure  without  feeling  that  he  was 
far  ahead  of  his  generation  in  his  recognition  of  the  important 
role  played  by  these  animal  parasites. 

Pfeiffer  also  set  the  first  example  in  a  careful  study  of  endemic 
cancer  and  of  localities  in  which  it  occurs.  He  presents  a  small 
map  of  the  village  of  Grossobringen  in  the  neighborhood  of 
Weimar.  The  little  village  contains  about  six  hundred  inhabi- 
tants. During  the  previous  twelve  years  nearly  three  times  as 
many  had  died  of  cancer  as  of  tuberculosis.  He  showed  that 
in  this  small  town  the  mortality  rate  from  cancer  was  much 
higher  than  of  the  adjoining  country  or  villages.  While  it  can- 
not be  said  that  he  presented  a  reasonable  explanation  therefor^ 
this  report  of  Pfeiffer's  must  still  stand  as  an  illustration  of  topo^ 
graphical  study  of  the  most  important  kind,  antedating  Behla's 
similar  investigation  of  the  town  of  Liickau,  to  which  reference 
has  often  been  made.  But  I  must  pass  on,  lest  other  matters 
of  importance  in  this  connection  be  neglected. 

Certain  observances  have  been  made  regarding  these  parasitic 
forms  which  may  be  stated  somewhat  succinctly  as  follows  : 

These  organisms  can  be  found  in  regional  lymph  nodes  before 


ADDKESS    OF    THE    PRESIDENT.  I9 

epithelial  deposits  are  detected  in  the  same.  This  would  seem 
to  imply  that  they  travel  ahead  of  the  epithelial  cells,  and  would 
seem  also  to  take  away  the  force  of  that  argument  which  was 
perhaps  put  forward  first  by  Rindfleisch,  who  spoke  of  the  in- 
fectivity  of  epithelial  cells.  The  parasites,  thus  being  much 
smaller,  may  much  more  easily  enter  the  lymph  stream  when 
liberated. 

The  constant  occurrence  of  young  forms  of  parasites  around 
the  periphery  of  a  growing  tumor,  where  they  more  easily  get 
into  both  blood  and  lymph  streams,  is  also  of  significance,  taken 
with  the  above.  Just  how  early  they  make  this  entrance  into 
the  current  is  a  matter  yet  to  be  determined,  as  also  whether 
there  is  any  clinical  or  pathological  sign  by  which  such  event 
may  be  indicated. 

In  all  cancer  cadavers  so  far  examined  we  have  found  organ- 
isms in  all  the  organs,  and  even  in  the  peripheral  blood,  in 
every  instance,  showing  how  widely  the  organisms  are  thus 
diffused  and  the  far-reaching  effect  of  a  primarily  local  infec- 
tion. Also  all  patients  so  far  examined  in  whom  cachexia  has 
been  extreme  have  given  the  same  result  so  far  as  the  periph- 
eral blood  was  concerned.  They  seem  always  to  be  found  in 
this  fluid. 

Malignant  lymphoma  is  a  disease  about  which  in  times  past 
no  small  differences  of  opinion  have  existed.  This  would  appear 
from  the  variety  of  names  which  have  been  given  to  it,  if  on  no 
other  account.  It  certainly  presents  a  great  variation  in  degree 
of  malignancy,  some  cases  being  exceedingly  rapid  and  acute, 
and  some  slow.  In  two  cases  of  mine  of  more  rapidly  growing 
type,  one  of  which  was  fatal  without  operation,  the  other  under- 
going it  and  recovering,  parasites  were  found  in  the  circulating 
blood — in  the  former  instance  seven  days  before  death.  Such 
cases  as  these  would  seem  to  be  instances  of  primary  lymph  or 
recurring  infection.  The  more  rapid  in  type  the  greater  the 
danger  and  degree  of  haematogenous  infection.  The  slower 
forms  of  this  kind  are  commonly  those  usually  known  as 
Hodgkin's  disease,  appearing  in  its  slow  type,  or  at  least  are 
barely  distinguishable  from  it.    The  microscopical  changes  in  the 


20  PARK, 

lymph  nodes,  disregarding  changes  in  the  blood,  which  are  seen 
in  malignant  lymphoma.  Hodgkin's  disease,  and  leukaemia,  are 
barely  distinguishable  from  each  other,  if  at  all.  So,  too,  the 
changes  in  the  spleen  in  chronic  leukaemia,  chronic  malaria, 
and  splenomegaly  (Banti's  disease),  barring,  of  course,  increase 
of  leucocytes  in  the  former  and  the  presence  of  malarial  para- 
sites in  malaria,  are  barely  distinguishable  from  each  other. 
We  seem  to  have  two  quite  different  types  of  lymph  infection 
— those  in  which  the  lymph-nodes  especially  are  involved,  as 
in  malignant  lymphoma  and  Hodgkin's  disease,  and  those  in 
which  the  spleen  especially  is  involved,  as  in  the  disease  last 
mentioned.  The  position  of  malaria  at  one  end  of  this  list  and 
of  malignant  lymphoma  at  the  other,  protozoa  being  respon- 
sible for  each  of  them,  would  seem  to  imply  that  all  the  inter- 
mediate conditions  must  necessarily  be  regarded  as  protozoan 
infections,  aside  from  the  actual  microscopical  findings.  In  this 
respect  the  recent  work  of  Lovvit,  which  is  exceedingly  sug- 
gestive, must  not  be  overlooked. 

Those  diseases  in  which  enlargement  of  the  spleen  forms  a 
prominent  feature  have  been  in  times  past  attacked  surgically 
until  the  number  of  failures  in  attempting  to  relieve  lymphatic 
spleens  has  led  almost  to  the  abandonment  of  splenectomy  for 
this  purpose.  The  primitive  form  of  splenomegaly  (Banti's  dis- 
ease) has  given  much  better  results  after  operation  than  any  of 
the  other  morbid  conditions  of  the  spleen,  and  this  may  now  be 
explained,  since  in  this  condition  the  infection  is  still  local,  in 
whole  or  in  part,  and  more  resembles  malignant  lymphoma.  If 
leukremia  is  a  protozan  disease,  as  Lowit  claims,  it  is  on  a  par 
with  malaria,  and  must  be  regarded  as  a  specific  infection  of  the 
leucocytes  like  malaria,  in  which  case  splenectomy  would  be 
very  much  less  promising.  It  is  only  when  the  lymph  nodes 
or  spleen  are  primarily  infected  and  most  conspicuously  in- 
volved that  the  case  becomes  essentially  a  surgical  one. 

Cancer  begins  as  a  purely  local  infection.  This  is  a  statement 
which  I  have  repeated  for  many  years,  and  which  would  seem 
to  be  verified  by  our  recent  work  in  Buffalo.  It  kills  by  becom- 
ing generalized.     This   is  also  true  of  tuberculosis,  and  while 


ADDRESS     OF    THE     PRESIDENT.  21 

there  are  possible  exceptions  in  each  case,  the  general  state- 
ment thus  made  can  scarcely  be  denied.  Miliary  carcinoma- 
tosis is  not  much  more  rare  than  miliary  tuberculosis,  and  these 
constitute  apparent  exceptions  to  the  above  rule.  Even  they, 
however,  do  not  prove  that  the  disease  does  not  have  a  local 
beginning.  In  each  case  operation,  if  done  before  general  in- 
fection has  occurred,  or  metastasis  has  taken  place,  is  exceed- 
ingly promising,  if  done  thoroughly.  This  statement,  of  course, 
is  backed  up  by  universal  experience,  but  finds  its  explanation 
in  what  I  have  already  said.  Operations  done  later  are  pallia- 
tive in  that  thereby  a  large  focus,  or  depot,  or  principal  source 
of  supply  is  removed,  its  removal  not  only  lessening  danger  of 
general  dissemination,  but  permitting  the  blood  to  assert  its 
own  normal  parasiticidal  properties. 

More  specific  illustration  of  this  statement  may  be  found  in 
cancer  of  the  stomach,  where  a  successful  gastro-enterostomy 
saves  the  patient  from  death  by  starvation,  but  does  not  avert 
his  final  cachexia  and  terminal  h?ematogenous  infection.  It 
prolongs  his  life  only  indirectly  and  for  but  a  short  time.  On 
the  other  hand,  radical  operation  when  successfully  done  seems 
to  really  prolong  life  and  to  remove  cachexia,  as  theoretically 
should  be  the  case  when  the  principal  source  of  infection  is 
extirpated. 

Take  the  case,  again,  of  a  successful  splenectomy  for  primary 
splenomegaly.  It  at  all  events  produces  great  temporary  benefit, 
and  often  leads  to  a  practical  cure.  It  has  hitherto  been  sup- 
posed that  the  splenic  enlargement  was  due  to  absorption  of 
toxic  substances  from  the  intestines.  If  this  were  really  the 
explanation  splenectomy  would  be  ridiculous.  On  the  other 
hand,  if  the  primary  infection  be  in  the  spleen  and  the  source 
of  supply  limited  to  that  organ,  then  its  removal  would  be  most 
strongly  indicated  and  should  prove  of  the  greatest  benefit.  It 
remains  yet  to  be  positively  demonstrated  that  Banti's  disease 
is  really  a  protozoan  infection,  since  I  doubt  if  yet  any  inocula- 
tions of  such  splenic  pulp  have  ever  been  made  into  animals.  It 
is,  however,  a  promising  field  for  research. 

If  these  statements  have  aught  of  actual  value,  this  value  is 


22  PARK, 

extreme,  since  they  should  teach  that  in  dealing  with  primary 
lymphatic  infections  of  such  structures  as  the  spleen  and  lymph 
nodes  extirpation  done  early  is  of  the  greatest  importance  and 
should  not  be  neglected.  It  is  most  indicative  also,  in  my  esti- 
mation, that  in  our  laboratory  experiences  Gaylord  succeeded  just 
as  well  when  inoculating  animals  by  using  old  dry  lymph  nodes 
as  by  introducing  fresh  elements.  This  suggestion  is,  so  far  as 
I  know,  original  with  him,  and  seems  to  have  a  far-reaching 
importance,  that  organisms  may  remain  in  the  dry  tissues  for 
considerable  lengths  of  time  and  still  prove  effective  when  in- 
oculated. This  is,  however,  just  what  we  see  with  vaccine 
lymph,  for  instance,  while  the  resemblances  between  the  pro- 
tozoa of  such  lymph  and  those  of  cancer  have  already  been 
strongly  touched  upon. 

I  want  to  make  it  as  evident  as  possible  that  carcinoma  as  a 
type  of  disease  is  in  every  instance  an  example  of  epithelial  in- 
fection. Sarcoma,  on  the  other  hand,  is  an  infection  of  con- 
nective tissue,  probably  by  the  same  organisms,  the  tissue  cells 
reacting  somewhat  differently.  It  would  seem,  so  far  as  we 
have  ^one,  that  different  forms  of  parasites  have  specific  ten- 
dencies in  one  direction  or  the  other;  but  it  will  take  years  of 
minute  and  careful  study  to  show  which  kind  of  parasite  pre- 
fers one  or  the  other  of  these  tissue  cells.  Up  to  a  time  within 
a  (ew  years  ago,  and  quite  easily  within  our  recollection,  ma- 
laria was  almost  as  much  a  mystery  as  has  been  cancer.  Now, 
we  recognize  at  least  three  distinct  types  of  malarial  parasite, 
and  talk  and  think  of  these  organisms  as  if  we  were  reasonably 
acquainted  with  them.  We  have,  then,  ample  grounds,  reason- 
ing by  analogy,  for  supposing  that  cancer  organisms  may  in 
some  manner  manifest  specific  inclinations.  Moreover,  those 
animals  which  were  inoculated  with  sarcoma  showed  predom- 
inant sarcomatous  lesions,  although  epithelial  infection  was  not 
entirely  wanting.  For  instance,  in  the  first  animal  inoculated 
from  my  first  case,  which  was  so  carefully  worked  up,  although 
the  predominant  lesion  was  adenocarcinoma  of  the  lung,  it  was 
nevertheless  found  that  all  of  the  splenic  follicles  (which  are  of 
connective  tissue  origin)  were  likewise  infected. 


ADDRESS    OF    THE    PRESIDENT.  23 

Authentic  instances  of  mixed  sarcoma  and  carcinoma  are,  in 
man,  clinically  rare,  but  we  may  note,  for  instance,  in  Cullen's 
recent  work  the  frequency  with  which  myoma  and  uterine  can- 
cer are  associated,  and  this  is  made  still  more  apparent  by 
Wadsworth's  recent  paper  illustrating  the  frequent  occurrence  of 
these  lesions. 

An  entirely  different  aspect  of  this  question  is  still  left  un- 
touched by  our  researches,  and  one  to  which  in  time  past  I  have 
invited  your  attention,  and  that  is  the  possibility  of  spontaneous 
retrocession  or  disappearance  of  malignant  growths.  I  had 
thought  to  get  together  for  presentation  to  you  at  this  time  the 
views  and  reports  of  various  surgeons,  in  all  parts  of  the  world, 
upon  this  topic,  but  was  prevented  doing  this  by  press  of  other 
work.  I  have  for  years  maintained  that  in  rare  instances  ma- 
lignant tumors  have  undergone  a  spontaneous  and  mysterious 
retrocession  for  which  it  was  impossible  to  account  in  any 
known  way.  While  some  surgeons  have  denied  that  this  is  pos- 
sible, others  have  maintained,  as  I  do,  that  it  has  occurred  under 
their  personal  observation.  Most  recently,  in  this  connection, 
similar  instances  have  been  reported  by  one  of  our  medical 
confreres.  Osier/  whom  we  surgeons  always  delight  to  honor. 
There  is  nothing  in  the  protozoan  theory  of  cancer  which  makes 
this  appear  less  possible  or  plausible  than  before,  nor  is  there 
anything  which  shows  it  to  be  impossible.  We  see  startling 
recovery  from  other  infections  in  cases  where  hope  had  been 
abandoned,  and  there  is  no  reason  to  think  that  such  a  thing 
is  impossible,  even  in  dealing  with  so  dreadful  a  condition  as 
cancer. 

'  American  Medicine,  April  13,  1901,  vol.  i.  p.  65. 


THE  EARLY  SIGNS  OF  CARCINOMA  OF  THE 
UTERUS. 


By  THOMAS  S.  CULLEN,  M.D., 

BALTIMORE. 


Dr.  Cullen  gave  a  lantern  exhibition  illustrating  the  early- 
points  in  the  diagnosis  of  cancer  of  the  uterus.  In  commencing, 
he  briefly  outlined  the  normal  histology  of  the  uterus,  showing 
sections  of  the  squamous  epithelium  of  the  vaginal  portion,  the 
racemose  glands  of  the  cervix,  with  their  characteristic  high 
cylindrical  and  pale-staining  epithelium,  and  the  tubular  glands 
of  the  body.  He  pointed  out  that  from  each  of  these  varieties 
of  epithelium  a  different  form  of  carcinoma  may  develop. 

Squamoiis-celled  Carcinoma  of  the  Cervix.  The  suspicious 
changes  in  the  epithelium  near  the  edge  of  the  growth  were 
shown.  Then  the  gradual  transition  of  normal  into  carcino- 
matous epithelium  portrayed,  and  finally  the  involvement  of  the 
underlying  stroma.  Great  stress  was  laid  on  the  increase  in 
size  of  the  cell,  associated  with  the  formation  of  large,  irregular, 
and  deeply-staining  nuclei. 

Adenocarcinoma  of  the  Cervix.  Several  examples  of  early 
gland  alteration  were  given  and  of  carcinoma  developing  from 
the  surface  epithelium.  Gross  specimens  were  also  shown 
where  the  organ  was  normal  in  size  and  contour,  and  where, 
without  the  timely  aid  of  the  microscope,  a  positive  diagnosis 
would  have  been  impossible. 

Adenocarcinoma  of  the  Body  of  the  Uterus.  The  doctor  pointed 
out  that  the  microscope  is  of  the  greatest  value  in  the  diagnosis 
of  carcinoma  of  the  body  and  at  a  time  where  the  symptoms 
or  the  bimanual  examination  reveal   little.     He  demonstrated 


SARCOMA    OF    THE     UTERUS.  2$ 

slides  showing  a  commencing  tit-like  outgrowth  from  the  sur- 
face of  the  mucosa,  and  traced  this  until  the  typical  carcinoma 
had  developed;  the  commencement  of  the  carcinoma  in  the 
glands  was  also  depicted.  Much  stress  was  laid  on  the  gland 
grouping  and  upon  the  size  and  staining  reaction  of  the  cells. 
The  doctor  said  that  the  diagnosis  can  be  made  in  nearly  every 
instance,  even  if  no  muscular  tissue  be  present.  Many  cases 
were  cited,  the  scrapings  being  shown,  and  then  the  diagnosis 
clinched  by  the  gross  specimen  after  removal. 

The  doctor  briefly  mentioned  certain  changes  that  might  be 
mistaken  for  commencing  carcinoma  of  the  body.  Among 
these  were  alterations  due  to  imperfect  hardening,  to  gland 
hypertrophy,  and  occasionally  to  endometritis.  In  conclusion, 
he  pointed  out  the  necessity  of  having  a  thorough  knowledge 
of  the  normal  mucosa  before  attempting  a. study  of  the  patho- 
logical changes. 


BRIEF  CONSIDERATION   OF   CASES   OF   CANCER 

OF  THE  BREAST   TREATED  AT  THE  JOHNS 

HOPKINS    HOSPITAL   SINCE    1889. 


BY  W.  S.  HALSTED,  M.D., 

BALTIMORE. 


Dr.  Halsted  explained  that  in  the  Johns  Hopkins  Hospital 
drawings  are  made  of  all  cases  of  cancer,  and  paintings  are 
made  of  some.  Some  320  cases  of  cancer  of  the  breast  have 
been  operated  upon  in  the  above-named  hospital  since  1889, 
and  about  150  of  these  during  the  past  three  years.  There 
have  been  450  cases  of  tumor  of  the  breast  since  1889;  of  these 
only  3  were  sarcoma,  and  but  i  of  these  was  primary.  Adeno- 
carcinoma is  not  very  malignant,  but  always  becomes  malignant. 
Dr.  Halsted  explained  the  difficulty  of  compiling  trustworthy 
statistics.  Many  hopeless  cases  were  operated  upon  simply  for 
temporary  relief,  and  these  should  not  be  counted  in  with  more 
hopeful  cases.  He  had  divided  his  cases  into  three  groups  : 
(l)  Those  from  which  the  axillary  and  supraclavicular  glands 
were  removed  at  the  primary  operation  ;  (2)  those  from  which 
the  supraclavicular  glands  were  not  removed  until  a  secondary 
operation  ;  (3)  those  from  which  the  supraclavicular  glands  were 
not  removed  at  all.  Local  recurrence  occurred  in  group  (i)  in 
II  per  cent.,  in  group  (2)  in  20  per  cent.,  and  in  group  (3)  in  9 
per  cent,  of  cases.  In  group  (i)  45  per  cent.,  in  group  (2)  33 
per  cent.,  and  in  group  (3)  43  per  cent,  were  cured.  Intra- 
canalicular  myxomas  and  fibromas  are  often  spoken  of  as 
sarcoma,  but  they  are  not  such. 


LATE  RESULTS  OF  THE  TREATMENT  OF  INOPER- 
ABLE SARCOMA  WITH  THE  MIXED  TOXINS 
OF   ERYSIPELAS   AND    BACH.LUS 
PRODIGIOSUS. 

By  WILLIAM  B.  COLEY,  M.D., 

NEW   YORK   CITY. 


In  May,  1894, 1  was  highly  honored  by  an  invitation  from  the 
American  Surgical  Association  to  read  my  first  paper  upon  the 
treatment  of  inoperable  malignant  growths  with  the  mixed 
toxins  of  erysipelas  and  bacillus  prodigiosus.  The  results  up 
to  that  time,  though  remarkable,  covered  a  comparatively  small 
number  of  cases  and  had  not  stood  the  test  of  time.  Yet  the 
words  of  kindly  encouragement  then  received  from  the  mem- 
bers of  the  American  Surgical  Association  did  much  to  stimu- 
late my  enthusiasm  and  helped  me  to  persevere  during  the 
period  of  doubt  and  discouragement  that  necessarily  attend 
the  introduction  of  any  new  method  of  treatment  of  malignant 
tumors,  and  especially  the  treatment  of  malignant  tumors  already 
pronounced  inoperable  and  hopeless  by  competent  authorities. 

Seven  years  have  passed  since  the  reading  of  the  paper 
referred  to,  and  just  a  decade  since  the  beginning  of  the  ex- 
periments of  Dr.  Bull  and  myself  with  the  living  cultures  of 
erysipelas  in  inoperable  malignant  tumors  ;  and  the  question 
may  well  be  asked  by  the  profession,  "  Has  the  toxin  method 
fulfilled  any  of  the  early  hopes  and  claims  ?  In  other  words, 
just  what,  in  brief,  is  its  proper  place  in  the  therapeutics  of 
malignant  tumors  ?" 

This  question  is  certainly  a  fair  one,  and  I  shall  attempt  to 
answer  it  in  the  briefest  possible  way  and  do  it  after  the  man- 
ner of  the  judge  rather  than  the  advocate. 


28  COLEY, 

The  results  of  this  method  during  the  last  three  years  have 
given  me  no  reason  to  change  the  conclusions  expressed  in  my 
earlier  papers,  and  I  have  nothing  new  to  add  in  the  way  of 
improvement  in  technique  or  of  preparing  the  toxins.  While 
the  results  are  far  better  in  spindle-celled  sarcoma  than  in  any 
other  form,  there  have  been  a  sufficient  number  of  round-celled 
sarcomas  successfully  treated  to  make  it  advisable  to  give  every 
patient  with  inoperable  sarcoma  the  benefit  of  a  brief  trial.  If 
no  improvement  has  occurred  at  the  end  of  three  to  four  weeks 
of  daily  injections,  the  treatment  is  not  likely  to  be  successful. 
If  improvement  does  occur,  the  treatment  should  be  kept  up, 
either  until  the  tumor  has  entirely  disappeared  or  until  it  has 
become  evident  that  the  injections  have  lost  their  inhibitory  in- 
fluence. The  toxins  may  be  given  for  long  periods  in  moderate 
doses  without  harm  to  the  patient.  The  risks  of  the  treatment 
are  practically  nil  if  proper  precautions  are  observed.  In  up- 
ward of  two  hundred  cases  I  have  had  but  two  deaths,  both  of 
which  occurred  more  than  five  years  ago.  It  should  be  remem- 
bered that  the  method  is  advised  only  in  inoperable  sarcoma; 
in  other  words,  in  the  entirely  hopeless  cases.  The  percentage 
of  probable  cures  depends  largely  upon  the  type  of  cell,  varying 
from  perhaps  3  or  4  per  cent,  in  the  round  celled  to  nearly  50 
in  the  spindle-celled  variety.  Up  to  the  present  time  I  have 
had  no  success  with  the  toxins  in  the  treatment  of  melanotic 
sarcoma,  although  I  have  tried  the  method  in  about  a  dozen 
cases.  In  some  of  these  cases  the  disease  was  held  in  check 
for  some  time,  but  after  a  longer  or  shorter  period  the  inhibi- 
tory action  of  the  toxins  was  in  some  way  lost.  Lympho- 
sarcomas of  the  neck  form  another  class  that,  up  to  the  present 
time,  justifies  a  prognosis  almost  as  bad  as  that  in  melanotic 
growths.  Although  I  have  treated  a  large  number  of  such  cases 
most  carefully  and  persistently,  I  have  not  as  yet  had  a  single 
permanent  success.  These  cases  are  nearly  all  of  very  rapid 
growth  and  very  highly  malignant.  It  should  be  borne  in 
mind  that  these  lymphosarcomas  of  the  neck  are  also  prac- 
tically hopeless  from  the  start  from  an  operative  point  of  view. 
Butlin  states  that  he   has   been    unable  to  find   a   record  of  a 


TREATMENT    OF    INOPERABLE    SARCOMA.  29 

single  case  in  which  a  cure  has  resulted  from  operation.  In  spite 
of  these  discouraging  results  in  melanotic  sarcomas  and  lympho- 
sarcomas of  the  neck,  the  remarkable  inhibitory  action  of  the 
toxins  that  I  have  observed  in  certain  tumors  of  these  varieties 
justifies  us  in  advising  a  thorough  trial  of  the  treatment  in  all 
such  cases,  unless  the  disease  is  very  far  advanced  or  has  already 
become  generalized.  After  generalization  has  occurred — what- 
ever be  the  variety  of  sarcoma — I  doubt  that  any  permanent 
result  can  ever  be  obtained  by  the  toxins. 

In  August,  1898/  I  published  my  results  in  140  cases  of 
inoperable  sarcoma  treated  with  the  mixed  toxins.  In  24  of 
these  the  tumor  completely  or  partly  disappeared.  Eighty- 
four  of  this  series  were  round-celled  sarcomas;  21  spindle- 
celled;  9  melanotic;  2  chondrosarcoma;  12  were  sarcomas 
(diagnosis  confirmed  by  the  microscope,  but  type  of  cell  not 
stated) ;  6  were  inoperable  sarcomas,  clinical  diagnosis  only, 
combined  with  a  history  of  repeated  recurrence  in  most  cases. 

In  40,  or  slightly  less  than  half  of  the  round-celled  cases, 
there  was  more  or  less  improvement,  as  shown  by  decrease  in 
size  and  cessation  of  growth.  In  only  three  of  these  was  the 
treatment  successful. 

Of  the  21  cases  of  spindle-celled  sarcoma,  10  disappeared 
entirely,  and  all  the  remainder  showed  marked  improvement. 

In  melanotic  sarcoma,  as  I  have  stated,  I  have  had  no  suc- 
cesses. It  should  be  noted,  however,  that  Dr.  George  R. 
Fowler,  of  Brooklyn,  has  reported  one  case  of  melanotic  sar- 
coma of  the  tonsil  and  fauces,  which  entirely  disappeared  under 
the  use  of  the  mixed  toxins.  The  patient  remained  well  for  two 
years,  when  a  local  recurrence  followed  and  proved  fatal. 

In  addition  to  these  personal  results  the  paper  contained  a 
summary  of  results  in  35  cases  successfully  treated  by  other 
surgeons  employing  the  same  method.  Of  these  35  cases,  10 
were  round-celled;  10  spindle-celled;  in  5  the  diagnosis  was 
clinical  only;  in  5  there  was,  in  addition  to  the  clinical  signs 
of  sarcoma,  a  history  of  recurrence  after  operation  ;  in  4  the 

'  Journal  of  the  American  Medical  Association. 


30  COLEY, 

diagnosis  of  sarcoma  was  confirmed  by  microscopical  examina- 
tion, but  the  type  was  not  stated ;  i  was  an  endothelio-sarcoma. 

Of  these  35  cases,  26  disappeared  completely;  2  others 
decreased  so  much  that  only  a  small  node  was  left,  which  was 
easily  excised.  One  of  the  latter  cases  was  well  three  years 
and  the  other  one  year  at  the  time  of  the  report. 

Of  the  35  cases  referred  to,  14  were  well  over  two  years  and 
6  cases  over  three  years. 

At  the  time  of  my  report  (August,  1898)  8  of  my  cases  had 
remained  well  from  three  to  six  years.  I  have  made  a  very 
great  effort  to  trace  the  after-histories  of  these  patients,  with 
the  following  results  : 

Case  I. — Recurrent,  inoperable  spindle-celled  sarcoma  of  the  neck 
and  tonsil,  treated  with  the  injections  of  the  living  cultures  of  ery- 
sipelas in  May,  1891,  for  four  months,  during  which  time  a  severe 
attack  of  erysipelas  occurred.  The  tumors  nearly  disappeared  and 
the  patient  recovered  perfect  general  health.  He  remained  well  for 
eight  years,  at  which  time  the  malignancy  reappeared  and  proved  fatal 
during  the  following  year. 

Case  II. — Recurrent  mixed-celled  sarcoma  (round,  oval,  and 
spindle)  of  the  back  and  groin.  The  patient  was  first  treated  in 
April,  1892,  with  the  living  bouillon  cultures  of  the  streptococcus  of 
erysipelas.  The  tumor  entirely  disappeared.  It  recurred  two  months 
later,  and  finally  disappeared  under  the  mixed  toxins.  During  the  treat- 
ment the  patient  had  four  attacks  of  erysipelas,  artificially  produced. 
He  remained  well  for  three  and  one-fourth  years;  then  had  an  intra- 
abdominal recurrence,  of  which  he  died  in  about  six  months. 

Case  III. — Inoperable  spindle-celled  sarcoma  of  the  abdominal  wall 
and  pelvis,  7x5  inches  in  diameter.  The  patient,  a  boy,  fifteen  years 
of  age,  was  treated  at  the  New  York  Cancer  Hospital  in  January,  1893. 
The  tumor  entirely  disappeared  under  four  months'  treatment  with  the 
mixed  filtered  toxins.  The  boy  was  in  perfect  health  when  last  seen, 
between  seven  and  eight  years  after  treatment.  The  diagnosis  was 
confirmed  by  Dr.  H.  T.  Brooks,  pathologist  at  the  Post-Graduate 
Hospital. 

Case  IV. — Large,  inoperable  sarcoma  of  the  abdominal  wall.  The 
patient  (female,  aged  twenty-eight  years,  had  an  exploratory  laparotomy 
performed  in  August,  1893,  at  the  Massachusetts  General  Hospital, 


TREATMENT    OF    INOPERABLE    SARCOMA.  3I 

by  Dr.  Maurice  H.  Richardson.  Such  a  large  portion  of  the  abdom- 
inal wall  was  found  involved  that  removal  was  considered  impossible. 
A  portion  of  the  growth  was  excised  for  microscopical  examination, 
and  pronounced  spindle-celled  sarcoma  by  Dr.  W.  F.  Whitney,  path- 
ologist of  the  hospital.  The  treatment  with  the  mixed  toxins  was 
begun  in  October,  1893,  and  continued  for  about  four  months,  with 
the  result  that  the  tumor  entirely  disappeared.  The  patient  remains 
in  perfect  health  at  the  present  time,  nearly  eight  years  after  treatment. 

Case  V. — Spindle-celled  sarcoma  of  the  leg  and  popliteal  space, 
three  times  recurrent.  The  tumor  disappeared  under  the  toxins,  but 
recurred  one  and  one-half  years  later.  Amputation  below  the  tro- 
chanter was  performed,  but  a  growth  soon  appeared  in  the  gluteal 
region.  This  grew  in  size  very  rapidly,  and  was  quite  inoperable. 
The  toxins  were  administered  for  a  number  of  weeks ;  the  growth 
became  more  clearly  outlined  and  movable,  and  the  greater  portion 
of  it  was  removed  under  ether.  The  toxins  were  continued  after  the 
operation,  with  intervals  of  rest,  for  nearly  a  year.  The  remaining 
portion  of  the  tumor  disappeared,  and  the  patient  is  at  present — more 
than  four  years  afterward — in  perfect  health,  without  any  sign  of 
return. 

Case  VI. — Spindle-celled  sarcoma  of  the  scapular  region,  involving 
the  soft  parts  of  the  left  half  of  the  thoracic  wall.  The  patient,  a  girl, 
aged  sixteen  years,  was  admitted  to  the  New  York  Cancer  Hospital 
June  20,  1894.  The  tumor  had  started  in  the  left  scapular  region 
four  months  before,  and  had  grown  very  rapidly,  until  it  measured  13 
inches  vertically  behind,  7  inches  in  front.  The  growth  seemed  ad- 
herent to  the  scapula  and  the  ribs ;  it  was  about  two  inches  in  thick- 
ness in  its  most  protuberant  part.  A  portion  from  this  region  was 
removed,  under  cocaine,  for  microscopical  examination,  and  the 
diagnosis  of  spindle-celled  sarcoma  was  made  by  Dr.  H.  T.  Brooks, 
pathologist  of  the  Post-Graduate  Hospital.  The  tumor  entirely  dis- 
appeared by  absorption,  without  breaking  down,  under  about  three 
months'  treatment.  The  after-history  of  this  patient  is  of  great  interest, 
and  will  very  shortly  be  published  in  detail  by  Dr.  Buxton  and  myself. 
She  remained  well  for  six  years,  and  then  developed  a  peculiar  growth 
in  the  region  of  the  right  scapula  and  right  pectoral  muscles.  A  por- 
tion of  the  tumor  removed  from  the  pectoral  region  in  October,  1900, 
seemed  microscopically  to  be  dense  fibrous  tissue  infiltrating  the  pec- 
toral muscle.  The  diagnosis  of  progressive  muscular  fibrosis  was 
made  by  Dr.  Buxton.     Shortly  afterward  a  piece  of  new  bone  about 


32  COLEY, 

two  inches  long  and  one  half  inch  in  diameter  was  removed  from  the 
pectoral  muscle.  A  little  later  a  new  bony  formation  occurred  in  the 
region  of  the  sternomastoid  muscle,  and  was  removed  under  ether. 
A  portion  of  soft  tissue  was  also  removed  from  the  scapular  region, 
and  microscopical  examination  showed  the  characteristic  changes  of 
myositis  ossificans. 

Case  VII. — Round-celled  sarcoma,  involving  omentum,  colon,  and 
a  loop  of  small  intestine.  The  diagnosis  was  made  by  Dr.  Willy  Meyer, 
and  confirmed  by  exploratory  laparotomy  and  microscopical  examina- 
tion of  a  portion  removed  by  Dr.  F.  Schwyzer,  pathologist  to  the  Ger- 
man Hospital.  The  toxins  were  begun  in  September,  1894,  and  con- 
tinued for  about  four  months.  The  tumor  slowly  diminished  in  size 
and  finally  disappeared.  A  year  later  several  calculi  were  removed 
from  the  gall-bladder,  with  no  evidence  of  a  tumor  to  be  found. 
The  patient  was  in  perfect  health  four  years  after  treatment. 

Case  VIII. — Inoperable  angiosarcoma  of  the  breast,  treated  in 
spring  of  1895.  The  growth  became  sufficiently  reduced  in  size  to 
be  easily  removed.  The  patient  was  well  when  last  seen,  about  six 
months  later. 

Case  IX. — Recurrent,  spindle-celled  sarcoma  of  the  palm  of  the 
hand.  The  growth  entirely  disappeared  under  two  months'  treat- 
ment. The  patient  remained  well  for  about  two  and  one-half  years, 
when  there  was  a  local  recurrence.  This  at  first  responded  to  the 
toxins,  but  later  they  evidently  lost  their  control.  Amputation  of 
the  arm  was  advised.  The  patient  refused  operation  and  chose  the 
Christian  Science  treatment  for  a  period  of  eight  months,  during 
which  time  the  tumor  increased  from  the  size  of  a  small  walnut  to 
that  of  a  cocoanut,  and  extended  nearly  to  the  elbow.  Amputation 
just  below  the  shoulder-joint  was  performed,  but  with  no  hope  of  doing 
more  than  removing  the  foul  and  sloughing  mass,  as  evidence  of 
generalization  had  already  appeared.  Death  occurred  about  four 
months  later. 

Case  X. — Recurrent,  spindle-celled  sarcoma  of  the  thigh  and  groin 
in  a  female,  aged  forty-eight  years.  The  tum.or  was  partially  removed 
in  March,  1896,  at  the  New  York  Hospital,  by  Dr.  Bull.  A  large 
mass  remained  in  the  inguinal  region,  and  there  was  marked  ccderaa 
of  the  whole  leg.  The  toxins  were  begun  on  May  30,  1S96,  and  con- 
tinued for  about  three  months,  at  the  end  of  which  time  the  tumor 
had  entirely  disappeared  and  the  left  leg  had  become  normal  in  size. 
The  patient  remained  well  for  about  a  year,  when  she  had  a  local 


TREATMENT    OF    INOPERABLE    SARCOMA.  33 

recurrence.  The  toxins  were  again  administered  with  temporary  im- 
provement, but  later  the  disease  returned  and  proved  fatal  in  less  than 
a  year. 

Case  XI. — Spindle-celled  sarcoma  of  the  iliac  fossa,  probably  start- 
ing in  the  ilium.  The  patient,  Mrs.  D.,  aged  forty  years,  first  noticed 
a  growth  in  the  right  iliac  region  in  the  early  part  of  1895.  This  in- 
creased steadily  in  size,  until  in  October,  1895',  exploratory  lapar- 
otomy was  performed  by  Dr.  Johnston,  of  Boston.  The  tumor  was 
about  the  size  of  a  cocoanut,  attached  to  the  ileum  as  well  as  to  the 
abdominal  wall,  and  was  totally  inoperable.  It  seemed  to  start  from 
the  crest  of  the  ilium.  The  diagnosis  of  spindle-celled  sarcoma  was 
made  by  Dr.  W.  F.  Whitney,  of  the  Massachusetts  General  Hospital. 
The  treatment  with  the  mixed  toxins  was  begun  by  Dr.  Farrar  Cobb, 
of  Boston,  in  November,  1895.  ^^  ^  letter  the  doctor  stated  that  at 
the  end  of  six  weeks'  treatment  the  growth  had  entirely  disappeared. 
In  May,  1896,  six  months  later,  the  patient  came  to  me  with  a  well- 
marked  recurrence,  extending  from  the  crest  of  the  ilium  nearly  to 
the  level  of  the  umbilicus  and  as  far  to  the  left  as  the  median  line. 
The  toxins  were  again  begun  and  continued,  with  intervals  of  rest,  for 
three  months,  when  the  patient  was  discharged  from  the  hospital  for  a 
few  months'  rest.  When  she  left  the  tumor  was  less  than  one-fifth  of 
its  original  size.  She  was  readmitted  to  the  hospital  in  November. 
The  tumor  had  increased  considerably  in  size  during  the  interval  of 
rest,  but  under  the  treatment  began  to  diminish  rapidly.  She  left 
the  hospital  in  June,  1897,  after  six  months,  when  the  tumor  had 
markedly  decreased  in  size,  and  her  general  health  was  good.  Owing 
to  a  change  of  address,  I  was  unable  to  trace  her,  and  believed  that  she 
had  probably  died,  until  I  received  a  letter  in  December,  1900,  three 
years  after  the  cessation  of  treatment,  more  than  four  years  from  the 
beginning,  in  which  she  stated  that  she  had  been  in  good  health  and 
been  supporting  the  family  during  the  entire  time.  She  had  noticed 
no  evidence  of  a  return  of  the  growth. 

Case  XII. — Inoperable  sarcoma  of  the  sacrum.  The  patient,  male, 
aged  thirty-eight  years,  had  a  rapidly  growing  tumor  in  the  upper  por- 
tion of  the  sacrum,  which  could  easily  be  felt  on  rectal  examination. 
His  weight  had  fallen  from  175  pounds  to  134  pounds  within  three 
months.  He  had  lancinating  pains  in  the  legs,  with  marked  lameness. 
The  clinical  diagnosis  of  sarcoma  was  made  by  Dr.  Francis  P.  Kinni- 
cutt,  and  confirmed  by  physicians  and  surgeons  who  examined  him  at 
St.  Luke's  Hospital.     No  microscopical  examination  was  made.     The 

Am  Surg  3 


34  COLEY, 

toxins  were  begun  in  May,  1S95.  The  injections  in  this  case  were  all 
made  in  the  gluteal  region,  remote  from  the  tumor.  The  prognosis 
given  was  extremely  bad.  However,  he  began  improving  immedi- 
ately after  the  beginning  of  the  treatment,  and  had  gained  28 
pounds  in  weight  two  months  later;  his  lameness  had  entirely  dis- 
appeared, and  six  months  later  no  trace  of  the  tumor  could  be 
detected  on  rectal  examination.  The  patient  was  in  perfect  health, 
weighing  175  pounds  when  last  seen,  nearly  four  years  after  the  treat- 
ment. 

Case  XIII. — Inoperable  sarcoma  of  the  iliac  fossa.  E.  S.,  male, 
aged  fourteen  years.  A  year  and  a  half  previously  he  had  been 
dragged  under  a  trolley  car,  causing  contusions  about  the  pelvis.  In 
January,  1895,  he  began  to  feel  pain  in  the  right  groin,  and  a  tumor 
soon  developed  in  the  right  iliac  fossa.  Exploratory  laparotomy  by 
Dr.  George  R.  Fowler,  of  Brooklyn,  on  March  7,  1897,  showed  a 
vascular  tumor,  filling  up  the  whole  right  iliac  fossa,  extending  up- 
ward three  inches  above  the  crest  of  the  ilium  and  Poupart's  ligament. 
The  tumor  was  so  vascular  that  Dr.  Fowler  did  not  think  it  wise  to 
remove  a  portion  for  examination.  He  closed  the  wound  and  re- 
garded the  case  as  entirely  hopeless.  The  condition  continued  to 
grow  rapidly  worse  after  the  operation,  and  on  April  10,  1897,  the 
mixed  toxins  were  given  as  a  last  resort.  The  treatment  was  carried 
out  under  my  direction  by  Dr.  G.  H.  Davis,  of  Brooklyn,  and  con- 
tinued for  several  months.  The  improvement  was  immediate  and 
rapid.  At  the  time  it  was  begun  the  patient  was  extremely  emaciated, 
with  marked  cachexia,  and  could  not  have  weighed  more  than  sixty 
pounds.  Within  the  next  three  weeks  he  was  walking  about  and  had 
gained  at  least  ten  pounds  in  weight.  Examination  of  the  abdomen 
showed  that  the  tumor  had  almost  entirely  disappeared.  The  injec- 
tions were  not  made  into  the  tumor,  but  into  the  gluteal  region  and 
upper  thigh.  A  few  months  later  he  developed  a  fluctuating  swelling 
over  the  ilium  behind.  The  skin  became  broken  and  a  slight  infec- 
tion occurred,  causing  some  temperature.  I  incised  the  swelling, 
evacuating  several  ounces  of  degenerated,  broken-down  tissue.  No 
bare  bone  was  detected  at  any  time.  The  curettings  of  the  walls  of 
the  cavity  were  carefully  examined,  and  not  the  slightest  evidence  of 
tuberculous  disease  could  be  found,  practically  verifying  the  original 
diagnosis  of  sarcoma.  Another  similar  operation  was  performed  on 
April  10,  1898.  The  boy  has  remained  in  good  health  up  to  the 
present  time,  four  years  after  treatment. 


TREATMKNT    OF    INOPERABLE    SARCOMA.  35 

Case  XIV. — Spindle-celled  sarcoma  of  the  abdominal  wall.  The 
patient,  a  girl  of  eighteen  years,  was  admitted  to  the  New  York  Cancer 
Hospital,  December  29,  1897,  with  a  tumor  in  the  lower  part  of  the 
abdomen  of  several  months'  duration.  Exploratory  operation  per- 
formed by  Dr.  Joseph  Brettauer  and  Dr.  George  W.  Jarmon.  A 
large  mass  was  found  in  the  abdomen,  both  intraperitoneal  and 
extraperitoneal.  It  was  regarded  as  entirely  inoperable.  A  portion 
was  removed,  and  the  diagnosis  of  spindle  celled  sarcoma  confirmed 
by  Dr.  Buxton,  pathologist  of  the  hospital.  After  thirty  injections — 
the  largest  dose  being  six  minims — of  the  filtered  toxins  the  tumor 
had  entirely  disappeared.  Very  little  pain  and  discomfort  resulted 
from  the  treatment,  and  but  four  chills  occurred  during  the  entire 
time.  The  patient  was  in  perfect  health,  without  recurrence,  one  and 
one-half  years  later,  when  she  returned  to  Germany. 

Case  XV. — Spindle-celled  sarcoma  of  the  parotid  gland.  The 
patient,  a  man  of  forty  years,  was  a  carpenter  by  occupation.  The 
tumor  was  first  noticed  early  in  1897.  It  grew  rapidly,  and  in  March, 
1897,  was  removed  by  Dr.  J.  W.  Wright,  of  Bridgeport,  Conn.  A 
second  and  a  third  operation  were  performed  in  April,  but  the  growth 
was  found  too  extensive  for  removal.  The  submaxillary  glands  of  the 
same  side  were  involved.  In  July,  1897,  the  patient  was  treated  with 
the  mixed  toxins  at  the  Bridgeport  Hospital  for  three  weeks  with  little 
improvement.  He  was  sent  to  me  by  Dr.  Wright,  August  10,  1897, 
for  advice  and  treatment.  Believing  that  perhaps  the  toxins  had  not 
been  pushed  to  their  full  limit,  I  began  with  daily  doses,  increasing  to 
the  point  of  producing  a  chill  and  temperature  of  103°  to  104°  nearly 
every  day.  The  patient's  excellent  condition  enabled  him  to  with- 
stand this  severe  treatment  without  loss  of  weight.  He  was  up  and 
about  the  ward  the  entire  time.  Some  improvement  was  evident  at 
the  end  of  two  weeks,  and,  although  this  was  not  great,  it  continued 
constant  until  the  middle  of  October,  when  the  disease  had  entirely 
disappeared.  The  patient  was  shown  before  the  New  York  Surgical 
Society  in  March,  1898,  in  perfect  health.  I  received  a  letter  from 
him,  dated  April  29,  1900,  stating  that  he  was  still  in  good  health, 
without  recurrence,  nearly  four  years  after  treatment. 

Case  XVI. — Three  times  recurrent  mixed-celled  sarcoma  of  the 
parotid.  Female,  aged  thirty-four  years.  The  tumor  had  been  re- 
moved three  times  by  Dr.  William  T.  Bull,  and  further  operation 
was  deemed  inadvisable.  Dr.  Bull  kindly  referred  the  case  to  me  for 
treatment  with  the   toxins.     The  injections  were  begun  in  January, 


36  CO LEY, 

1897,  and  continued  for  seven  months  in  very  small  doses.  The 
patient  was  extremely  nervous.  The  tumor  became  much  reduced 
in  size  and  very  movable,  so  that  most  of  the  tumor  could  be  easily 
removed  under  ether  anaesthesia.  It  would  have  been  impossible  to 
remove  all  of  it  without  sacrificing  the  facial  nerve.  The  toxins  were 
continued  after  the  operation  for  a  considerable  time  in  very  small 
doses,  just  sufficient  to  produce  a  chill.  The  patient  is  still  well  and 
free  from  recurrence,  more  than  four  years  later. 

Case  XVII. — Twice  recurrent  round-celled  sarcoma  of  the  lower 
lip.  The  patient,  a  little  girl,  five  years  of  age,  daughter  of  a  physician 
in  Tacoma,  Wash.,  was  referred  to  me  in  February,  1897.  The  diag- 
nosis of  round-celled  sarcoma  was  confirmed  by  the  pathologists  of  the 
Cancer  Hospital,  Drs.  Dunham  and  Buxton.  In  this  case  the  mixed 
toxins  were  used  for  about  six  weeks,  with  the  result  that  the  growth 
entirely  disappeared.  The  patient  has  remained  well  up  to  the  present 
time  (June  10,  1901),  more  than  four  years  after  the  treatment. 

Case  XVIII. — Eight  times  recurrent  spindle-celled  sarcoma  of 
the  chest  wall,  soft  parts.  The  patient,  a  surgeon  of  prominence, 
had  been  operated  upon  eight  times  for  rapidly  recurring  spindle- 
celled  sarcoma  of  the  chest  wall,  soft  parts.  The  intervals  between 
operation  and  recurrence  were  becoming  shorter  and  shorter  and 
the  character  of  the  growth  more  vascular  and  more  malignant. 
The  toxins  were  begun  in  November,  1894,  and  used  in  small  doses 
for  three  and  one-half  years,  with  intervals  of  rest.  The  patient 
gained  in  weight  under  the  treatment,  and  continued  to  perform  his 
daily  duties.  Two  to  three  small  nodules  were  removed  during  the 
treatment.  He  has  had  no  injections  now  for  nearly  four  years,  and 
there  has  been  no  evidence  of  return. 

Case  XIX. — Inoperable  sarcoma  of  the  tibia.  Male,  aged  twenty- 
five  years.  The  patient  was  admitted  to  the  General  Memorial  Hos- 
pital in  February,  1899,  with  a  recurrent  tumor  of  the  tibia,  for  which 
amputation  had  been  advised.  A  portion  of  the  growth  removed  had 
been  examined  by  Dr.  John  Caven,  Professor  of  Pathology  at  the 
University  of  Toronto,  and  pronounced  spindle-celled  sarcoma.  In 
view  of  this  report  I  believed  it  wise  to  give  him  the  benefit  of  a  short 
period  of  toxin  treatment  before  amputating.  After  about  two  months 
the  tumor  had  apparently  disappeared  and  the  injections  were  discon- 
tinued. The  tumor  disappeared  partly  by  sloughing,  and  the  granu- 
lating area  left  behind  became  infected  with  erysipelas,  there  having 
been  a  case  left  in  the  wards  some  months  before.     The  patient  had  a 


TREATMENT    OF     INOPERABLE    SARCOMA.  37 

very  severe  attack  of  erysipelas,  extending  over  the  whole  leg  and  por- 
tion of  the  body,  and  after  recovering  from  this  he  returned  home. 
He  remains  in  perfect  health  at  the  present  time,  and  has  continued 
his  occupation  as  farmer. 

Case  XX. — Large  chondrosarcoma  of  the  ilium,  which  disappeared 
under  the  treatment.  The  patient  remained  well  for  seven  months, 
when  a  recurrence  took  place,  which  proved  fatal  in  about  a  year's 
time. 

Case  XXI. — Recurrent  inoperable  tumor  of  the  upper  lip.  Diag- 
nosis, fibro-angioma.  Successfully  treated  with  the  toxin.  The  patient 
was  well  when  last  heard  of,  over  two  years  after  treatment. 

Case  XXII. — Inoperable  epithelioma  of  the  chin,  lower  jaw,  and 
floor  of  the  mouth.  The  growth  disappeared  entirely  under  four 
months'  treatment  with  the  mixed  toxins.  The  patient  was  well, 
without  recurrence,  when  last  seen,  four  years  after  treatment.  The 
case  was  referred  to  me  by  Dr.  George  R.  Fowler,  of  Brooklyn,  who 
regarded  it  as  entirely  inoperable,  and  the  diagnosis  had  been  con- 
firmed by  a  microscopical  examination  by  the  pathologist  of  the 
Methodist  Episcopal  Hospital. 

Case  XXIII. — Spindle-celled  sarcoma  of  the  palm  of  the  hand, 
three  times  recurrent ;  the  toxins  as  a  prophylactic  measure  immedi- 
ately after  last  operation.  The  patient  is  in  good  health  one  and  one- 
half  years  after  operation.  The  patient,  a  boy,  aged  six  years,  was 
operated  upon  by  Dr  J.  D.  Bryant,  in  1898,  for  acute  traumatic 
sarcoma  of  the  palm  of  the  hand.  A  small  operation  was  first  per- 
formed, and  later  a  more  radical  one,  with  removal  of  the  ring  and 
little  fingers  and  their  metacarpal  bones.  Recurrence  quickly  fol- 
lowed after  each  operation,  and  finally,  in  the  fall  of  1899,  a  sarco- 
matous tumor  appeared  in  the  axillary  region.  This  was  removed  also 
by  Dr.  Bryant,  and  as  soon  as  the  wound  had  closed  the  patient  was 
referred  to  me  for  the  toxin  treatment.  The  injections  were  given  in 
small  doses,  two  to  three  times  a  week,  for  about  three  months.  The 
boy  has  remained  in  good  health  up  to  the  present  time,  without 
recurrence. 

The  following  case  of  carcinoma  is  of  special  interest: 

Case  XXIV. — Extensive  recurrent  carcinoma  of  the  breast  follow- 
ing amputation  of  both  breasts  for  carcinoma.  The  toxins  were  used 
continuously  for  nearly  four  years.     The  patient  is  still  alive,  four  and 


35  CO  LEY, 

one-half  years  after  treatment.  The  patient,  ^Irs.  W.  H.,  aged  fifty- 
six  years,  was  operated  upon  by  Dr.  Maurice  H.  Richardson,  of  Bos- 
ton, for  carcinoma  of  both  breasts  October  8,  1895.  Recurrence  was 
first  noticed  in  June,  1896,  nine  months  after  the  primary  operation. 
Dr.  Richardson  advised  against  further  operation  and  referred  the 
patient  to  me  for  opinion  as  to  the  propriety  of  using  the  toxins.  I 
stated  that  I  believed  the  treatment  would  prove  of  only  temporary 
value  and  might  have  no  effect.  I  urged  the  removal  of  the  carcino- 
matous area,  which  at  this  time  was  about  three  to  four  inches  in  size, 
infiltrating  the  skin,  and,  as  soon  as  the  wound  was  healed,  to  begin  the 
toxins  in  the  hope  of  delaying  recurrence.  Dr.  Richardson  removed 
diseased  area  November  27,  1896.  On  January  ist,  before  the  wound 
had  entirely  healed,  new  nodules  appeared  in  the  outlying  skin  near 
the  anterior  axillary  line.  The  toxins  were  begun  on  January  10, 
1897,  and  continued  in  small  daily  doses  for  one  month.  The  small 
nodules  in  the  skin  disappeared.  After  a  short  interval  of  rest  her 
general  health  was  much  improved  compared  to  what  it  was  prior  to 
the  beginning  of  the  treatment.  She  returned  to  her  home  in  Massa- 
chusetts, and,  with  occasional  intervals  of  rest,  the  treatment  was  con- 
tinued in  moderate  doses  upward  of  three  years.  On  three  or  four 
occasions  some  minute  localized  skin  infiltrations,  not  more  than  one- 
fourth  inch  in  diameter,  were  removed  under  cocaine.  About  a  year 
ago  she  developed  ascites,  and  has  been  tapped  by  Dr.  Richardson  a 
number  of  times.  No  tumor  has  been  felt  in  the  abdomen,  although 
it  is  quite  possible  that  generalization  of  the  disease  has  taken  place. 
The  fact  remains  that  life  has  been  unquestionably  greatly  prolonged 
by  the  continued  use  of  small  doses  of  the  toxins  in  a  most  unpromis- 
ing case  of  double  recurrent  carcinoma  of  the  breast. 

This  case  is  of  great  interest,  as  it  shovv^s  that  in  certain  con- 
ditions the  toxins  may  be  used  to  advantage  even  in  carcinoma, 
especially  as  an  aid  to  partial  operation  or  as  a  prophylactic 
measure  against  recurrence. 

Another  case  of  rapidly  growing  recurrent  carcinoma  of  the 
breast  in  a  comparatively  young  woman,  aged  forty-two  years, 
with  involvement  of  axillary  glands,  was  kept  in  good  health, 
with  almost  complete  control  of  the  disease  for  nearly  two  and 
a  half  years  by  the  administration  of  small  doses  of  the  toxins 
two  or  three  times  a  week. 


TREATMENT    OF     INOPERABLE    SARCOMA.  39 

While  at  the  time  of  my  report  in  1898  eight  of  my  own  cases 
had  remained  well  from  three  to  six  years,  I  am  now  able  to 
report  fifteen  cases  now  passed  the  three-years'  limit.  Of  these, 
two  have  recurred  three  and  one-fourth  years  after  treatment, 
and  the  other  eight  years,  one  dying  of  metastasis  and  the 
other  of  local  recurrence. 

All  the  cases  comprising  the  foregoing  series  were  hopeless, 
inoperable  cases,  and  the  diagnosis  was  confirmed  by  the  micro- 
scope, with  two  exceptions,  and  in  these  the  history  of  the  case, 
together  with  the  clinical  appearances,  made  the  diagnosis  of 
sarcoma  unquestionable.  The  type  of  the  tumor  in  the  fifteen 
cases  that  passed  the  three-year  limit  was  as  follows  : 

Spindle-celled  sarcoma     .       •  .         .         .         .         .         .         .         .         .8 

Round-celled  sarcoma      ..........     2 

Mixed-celled  sarcoma       .         .         .         .         .         .         ...         .         .2 

Epithelioma     ............     i 

Sarcoma  (clinical  diagnosis  only)      ........     2 

It  is  worthy  of  special  note  that  two  of  the  successful  cases, 
now  well  three  and  three-fourths  and  four  and  one-fourth  years 
respectively,  are  sarcoma  of  the  parotid  gland.  Butlin,  in  his 
last  edition  of  Operative  Treatment  of  the  Parotid  Gland,  states 
that  "up  to  the  present  time  there  are  very  few  instances  of 
cure  by  operation  of  undoubtedly  malignant  disease  of  the 
parotid."  In  the  author's  two  cases  treated  by  the  toxins  the 
diagnosis  was  not  only  confirmed  by  a  competent  pathologist, 
but  further  by  a  history  of  repeated  recurrence  after  operation. 
Another  case  still  is  also  worthy  of  special  mention,  inasmuch 
as  it  shows  that  the  toxins  may  be  taken  for  long  periods  of 
time  without  harm.  The  patient,  a  well-known  physician,  with 
eight  times  recurrent  spindle-celled  sarcoma  of  the  soft  parts  of 
the  chest  (anteriorly),  was  treated  with  small  doses  of  the  mixed 
toxins,  with  varying  intervals  of  rest,  for  upward  of  two  years. 
The  patient  regained  his  usual  health,  and  has  now  been  per- 
fectly well  over  six  years  from  the  beginning  and  four  years 
since  the  cessation  of  the  treatment.  The  tumors,  while  origi- 
nally pure  spindle-celled,  were  becoming  more  mixed  with  round 
cells  and  more  vascular  with  each  recurrence.     In  other  words, 


40  COLEY, 

the  disease,  as  so  often  happens,  was  increasing  in  malignancy 
until  the  toxins  were  begun. 

In  addition  to  these  fifteen  cases  that  have  passed  the  three- 
year  limit,  eight  were  mentioned  in  which  the  tumors  disap- 
peared entirely.  One,  a  spindle-celled  sarcoma  of  the  abdominal 
wall,  was  well  one  and  one-half  years,  when  the  patient  returned 
to  her  home  in  Europe  and  was  lost  sight  of.  Another,  an 
extensive  round-celled  sarcoma  of  the  iliac  fossa,  was  well  one 
year,  and  then  lost  sight  of.  A  third,  a  spindle-celled,  recurrent 
sarcoma  of  the  leg,  is  now  in  perfect  health,  without  recurrence, 
nearly  two  years  after  treatment.  A  fourth,  a  twice  recurrent 
spindle-celled  sarcoma  of  the  palm  of  the  hand,  disappeared 
under  the  toxin  treatment,  and  the  patient  remained  well  two 
and  a  half  years,  when  the  tumor  recurred.  Refusing  amputa- 
tion of  the  arm,  she  was  under  the  care  of  a  Christian  Scientist 
for  eight  months,  during  which  time  the  tumor  in  the  hand 
reached  the  size  of  a  cocoanut  and  extended  above  the  elbow. 
Amputation  of  the  arm  just  below  the  shoulder-joint  was  then 
performed,  but  the  patient  died  of  metastasis  three  and  one-half 
months  later. 

A  fifth  case,  a  chondrosarcoma  of  the  ileum,  of  large  size, 
disappeared,  and  the  patient,  after  remaining  well  for  seven 
months,  had  a  recurrence,  which  proved  fatal  in  about  a  year's 
time.  A  sixth,  a  round-celled  angiosarcoma  of  the  breast,  was 
well  six  months  later,  when  the  patient  was  lost  sight  of.  A 
seventh,  a  recurrent  fibro-angioma  of  the  lip,  was  well  when  last 
heard  of,  over  two  years  after  operation ;  and  an  eighth  case,  a 
spindle-celled  sarcoma  of  the  thigh,  disappeared,  but  after  a 
year's  time  recurrence  took  place  locally  and  in  the  groin, 
which  no  longer  yielded  to  the  treatment. 

In  addition  to  these  personal  cases  I  will  mention  two  other 
cases  in  which  I  directed  the  treatment,  although  it  was  carried 
out  by  another  surgeon.  One  case  (Johnson's),  a  large  spindle- 
celled  sarcoma  of  the  pharynx,  entirely  disappeared,  and  the 
patient  was  well  more  than  six  years  later.  The  second  (Storr's, 
of  Hartford),  an  inoperable  sarcoma  of  the  breast  and  axilla,  dis- 
appeared under  seventy-six  injections  of  the  mixed  toxins,  and  is 


TREATMENT    OF    INOPERABLE    SARCOMA.  4I 

now  well  more  than  four  years  after  treatment.  The  diagnosis 
in  both  of  these  cases  was  confirmed  by  microscopical  examina- 
tion ;  in  the  latter  case  by  the  highest  authority  in  this  country, 
Prof.  William  H.  Welch,  of  Johns  Hopkins  University. 

The  results  of  this  method  during  the  last  two  years  give  no 
reason  to  change  the  conclusions  expressed  in  earlier  papers. 
Further  experience  has  confirmed  the  opinion  that  spindle-celled 
sarcoma  yields  far  better  results  than  any  other  variety,  although 
there  have  been  a  sufficient  number  of  round-celled  cases  success- 
fully treated  to  make  it  advisable  to  give  every  inoperable  case 
the  benefit  of  a  brief  trial.  If  no  improvement  has  occurred  at  the 
end  of  three  or  four  weeks,  with  daily  injections,  I  do  not  believe 
the  treatment  is  likely  to  prove  successful.  If  improvement  does 
occur,  the  injections  should  be  continued  either  until  the  tumor 
has  entirely  disappeared  or  it  has  become  evident  that  the  toxins 
have  lost  their  inhibitory  influence.  The  toxins  may  be  given 
for  long  periods  in  moderate  doses  without  harm  to  the  patient. 
The  risks  of  the  treatment  are  practically  ;///,  provided  proper 
precautions  are  observed.  In  upward  of  200  personal  cases 
there  have  been  but  two  deaths,  both  of  which  occurred  more 
than  five  years  ago.  The  percentage  of  probable  cures  depends 
largely  upon  the  type  of  the  cell,  varying  perhaps  3  to  4  per 
cent,  in  the  round-celled  to  nearly  50  per  cent,  in  the  spindle- 
celled. 

Thus  far  no  permanent  successes  have  been  obtained  in  mel- 
anotic growths  nor  in  lymphosarcomas  of  the  neck.  I  believe 
that  the  toxins  administered  in  small  doses  immediately  after 
primary  operations  for  sarcoma  offer  a  most  valuable  prophy- 
lactic measure  against  future  recurrence. 

The  results  thus  far  seem  sufficient  to  warrant  advising  the 
treatment  as  a  routine  measure  after  all  operations  for  primary 
sarcoma.  While  the  treatment  is  not  recommended  in  carcino- 
matous growths,  it  has  been  the  experience  of  the  writer  that 
in  many  cases  the  toxins  exert  a  marked  inhibitory  influence 
upon  carcinoma,  although  this  influence  is  rarely  curative.  The 
only  cases  of  carcinoma  in  which  the  toxins  are  likely  to  prove 
of  much  value  are,  I  think,  those  in  which  they  are  used  after 


42  TREATMENT    OF     INOPERABLE    SARCOMA. 

primary  or  secondary  operation  as  a  prophylactic  against  recur- 
rence. 

Up  to  the  present  time  sufficient  experience  is  lacking  to 
justify  one  in  making  any  definite  statements  as  to  how  much 
may  thus  be  accomplished.  I  still  believe  that  the  action  of  the 
toxins  upon  malignant  tumors  is  the  result  of  some  infectious 
micro-organism,  and  this  view  is  strongly  supported  by  the 
recently  expressed  opinion  of  Czerny. 


THE  INFLUENCE  OF  MENTAL  DEPRESSION  ON  THE 
DEVELOPMENT  OF  MALIGNANT  DISEASE. 


By  JOSEPH  D.  BRYANT,  M.D., 

NEW  YORK  CITY. 


Pericles,  about  five  hundred  years  before  the  birth  of  Christ, 
uttered  the  following:  "  One  sorrow  never  comes  but  brings  an 
heir  that  may  succeed  as  his  inheritor." 

It  cannot  properly  be  assumed  that  this  distinguished  Greek 
had  in  view  the  topic  now  before  us  when  he  uttered  this  dis- 
tinctive truism. 

However,  it  is  not  impossible,  even  at  this  early  date,  that 
Pericles'  wise  comprehension  of  things,  supplemented  by  the 
outcome  of  the  painstaking  heed  of  Hippocrates,  his  colaborer 
in  public  good,  might  not  have  exercised  a  prompting  influence 
in  the  giving  birth  to  this  expression. 

The  ancient  medical  writers,  beginning  with  Galen,  who  was 
born  A.D.  132,  taught  that  cancer  was  dependent  on  "  black 
bile,"  which  latter  in  Greek  is  synonymous  with  melancholia. 
Therefore,  the  causal  association  of  cancer  with  mental  depres- 
sion, the  handmaid  of  melancholia,  is  easily  understood,  and 
the  birth  of  the  idea  in  this  connection  could  hardly  have  been 
otherwise  than  quite  spontaneous. 

Nowhere  in  their  writings  do  we  find  the  statement  that  can- 
cer arises  from  any  form  of  mental  perturbation — a  fact  quite 
inevitable,  since  at  this  time  no  discrimination  could  be  made 
between  the  effect  of  the  worry  attendant  on  the  presence  of 
cancerous  disease  and  that  underlying  the  brooding  over  the 
wrongs,  the  griefs,  and  the  anxieties  of  the  period. 

If  Galen,  or  one  of  his  followers,  had  been  asked  whether 
cancer  could  develop  as  a  result  of  the  mental  burden  imposed 


44  BRYANT, 

by  human  cares  and  griefs,  he  would  doubtless  have  replied 
that  if  the  melancholic  state  predisposed  to  cancer  it  would  be 
quite  natural  for  an  individual  suffering  from  melancholia  to 
emphasize  the  darker  side  of  things,  and  be  correspondingly 
unhappy. 

Curiously  enough,  we  find  something  akin  to  this  reasoning 
in  modern  literature.  Virchow  quotes  Banos  with  approval  as 
stating  that  the  depression  which  is  often  seen  to  precede  can- 
cer of  the  stomach  may  be  a  part  of  the  disease. 

In  following  up  the  statements  of  the  various  standard  writers 
of  the  early  middle  ages  we  note  a  strict  adherence  to  the 
Galenic  view  of  cancer.  But  early  in  the  sixteenth  century  a 
change  in  this  respect  appears.  Instead  of  giving  but  a  single 
cause  for  cancer,  we  find  authors  mentioning  contributing 
factors,  such  as  trauma,  improper  diet,  etc.  Still,  we  do  not 
as  a  rule  find  any  allusion  to  the  causative  influence  of  mental 
depression. 

The  first  mention  of  this  causative  element  which  we  have 
encountered  is  by  Ambroise  Pare  (born  1510).  This  noted 
author  does  not,  indeed,  state  that  there  is  a  mental  factor  in 
the  etiology  of  cancer,  but  he  does  say  unquestionably  that 
mental  perturbation,  anger,  and  the  like  make  a  cancer  "  more 
fierce  and  raging,"  while  under  the  head  of  treatment  he  insists 
that  the  patient  must  eschew  fasting,  watching,  sorrows,  cares, 
and  mourning. 

At  least  three  of  Fare's  contemporaries  mention  a  mental  ele- 
ment in  the  causation  of  cancer.  Thus  Roderic  de  Castro  (1628), 
who  wrote  an  elaborate  monograph  on  diseases  of  women,  gives 
among  the  causes  of  scirrhus  of  the  breast,  "  cares,  watching, 
grief,"  and  later,  describing  cancer  of  the  uterus,  he  states  that 
"grief,  fear,  anxiety,  dejection,"  etc.,  may  be  among  the  causes. 

Vigierius  (1659),  who  is  said  to  have  written  a  monograph  on 
tumors,  states  in  his  work  on  medicine  and  surgery  that  among 
the  causes  of  cancer  are  "  violent  emotions,  excessive  vigils,  and 
affections  of  the  mind." 

Mercurialis  (1530)  also  enumerates  grief  and  fear  as  causes  of 
cancer. 


INFLUENCE    OF    MENTAL     DEPRESSION    ON     DISEASE.        45 

The  simplest  explanation  of  the  appearance  of  this  idea  in 
the  mediaeval  literature  is  probably  the  gradual  recognition  of 
the  fact  after  the  revival  of  learning  that  there  were  other  causes 
of  diseases  beside  the  "  humors."  Since  grief,  fear,  and,  in  gen- 
eral, the  painful  and  depressing  emotions,  came  to  be  recognized 
as  causes  of  disease  in  general,  it  would  be  natural  to  extend 
this  etiology  to  cancer,  the  more  readily  because  of  its  univer- 
sally recognized  association  with  the  melancholic  habit. 

Notwithstanding  these  isolated  mentions  of  a  mental  cause 
for  cancer,  the  great  majority  of  writers  continue  to  ignore  its 
importance,  as  in  the  early  past.  We  have  been  able  to  find 
but  a  few  clean-cut  exceptions  to  this  position. 

J.  Hoffman  (1660)  goes  very  fully  into  the  matter.  In  the 
chapter  on  ulcers,  including  cancer,  this  author  speaks  of  pro- 
longed grief  and  poignant  sadness,  and  even  of  unforeseen  terror 
as  important  factors  in  the  etiology  of  cancer.  He  explains  the 
connection  between  these  emotions  and  cancer  by  the  fact  that 
the  former  are  well  calculated  to  confine  the  secretions  and  cause 
stagnation  and  inspissation  of  them.  In  this  manner  prolonged 
sadness  leads  to  the  production  of  scirrhus  of  the  pancreas, 
mesentery,  and  liver.  Sudden  and  unexpected  terror  may  cause 
a  suppression  of  the  milk,  which,  stagnating  in  the  lactiferous 
ducts,  may  generate  a  scirrhus  of  the  breast. 

Von  Swieten  (1775)  enumerates  among  the  causes  of  cancer 
an  atrabiliary  disposition  of  the  blood  or  bile.  The  atrabilis^ 
according  to  the  ancient  physicians,  dependent  on  the  inspissa- 
tion of  blood  or  bile,  especially  in  the  abdominal  viscera,  pro- 
duces astonishing  anguish  and  grief,  leading  to  scirrhus  and 
cancers.  Doubtless  the  exploitation  of  a  mental  origin  of  can- 
cer by  these  eminent  medical  teachers  is  largely  responsible  for 
the  fact  that  reference  to  such  origin  begins  to  be  more  frequent 
in  standard  authors. 

The  next  prominent  champion  of  the  mental  origin  of  cancer 
appears  to  have  been  Sir  Astley  Cooper,  who,  in  writing  of  the 
influence  of  the  mind  in  predisposing  to  scirrhus,  expressed 
himself  substantially  as  follows  : 

Anxiety  of  mind,  tendency  to  the  presence  of  slow  fever,  and 


46  BRYANT. 

suppressed  secretions  are  the  predisposing  causes  of  the  com- 
plaint. A  mother  watching  with  anxiety  a  near  and  dear  rela- 
tive in  sickness,  deprived  of  her  natural  rest  and  inattentive  to 
the  deviation  from  health  in  her  own  person,  is  afterward  affected 
with  this  disease.  A  person  the  prey  of  disappointment  from 
reduced  circumstances  and  struggling  against  poverty,  when  her 
prospects  begin  to  brighten  finds  a  malignant  tumor  in  her 
breast.  A  costive  state  of  the  bowels,  a  dry  skin,  and  a  paucity 
of  other  secretions  attending  this  anxious  state  of  mind  lay  the 
foundations  of  the  destructive  process  that  awaits  her. 

The  details  of  this  statement  are  given  quite  in  full,  not  only 
because  of  the  great  eminence  of  their  author,  but  also  because 
the  extended  scope  of  their  presumptive  action  includes  the 
common  depressive  activities  of  everyday  life. 

Chomel,  the  French  clinician,  and  Lobstein,  a  German  bac- 
teriologist, are  reported  to  have  recognized  the  mental  origin, 
and  the  latter  is  stated  to  have  theorized  extensively  regarding 
the  rationale  of  its  causative  relationship. 

We  have  not  as  yet  succeeded  in  finding  the  passages  to 
which  subsequent  authors  allude. 

Boyle  and  Laennec  accepted  the  affirmative  side  of  the  con- 
troversy. At  a  little  later  period  we  note  the  first  active  oppo- 
sition to  the  mental  theory,  Velpeau  and  Lebert  both  stating 
their  unqualified  disbelief  in  the  existence  of  such  a  relation- 
ship. But  authorities  like  Virchow,  Paget,  Walshe,  and  some 
of  their  eminent  contemporaries  gave  a  qualified  allegiance  to 
the  passive  side  of  the  question.  Also,  the  same  idea  is  affirmed 
by  Rokitansky,  Scanzoni,  and  others. 

The  foundation  of  the  different  phases  of  the  contention  rest 
on  the  beliefs:  (i)  That  cancer  may  result  from  the  direct  influ- 
ence of  mental  depression ;  (2)  that  cancer  may  arise  indirectly 
from  mental  depression,  because  of  the  defective  nutrition  at- 
tendant upon  it;  (3)  that  mental  depression  exercises  in  no 
respect  influences  that  admit  of  sufficient  proof  to  warrant 
serious  discussion. 

Incidentally,  it  is  proper  to  mention  at  this  time  that  Crook- 
shank,  writing    in    1898  on  "Congenital   Observations  of  the 


INFLUENCE    OF     MENTAL     DEPRESSION     ON     DISEASE.       4/ 

Epiblast  in  an  Insane  Man,"  offered  the  suggestion  that  since 
the  central  nervous  system,  no  less  than  the  skin  and  its  ap- 
pendages, is  of  epiblastic  origin,  one  might  be  justified  in 
accepting  the  clinical  fact  that  cutaneous  abnormalities  fre- 
quently indicate  the  insane  diathesis. 

Regarding  the  first  proposition,  viz.:  that  cancer  results  from 
the  direct  influence  of  mental  depression,  Hughes  has  quite 
recently  written  repeatedly  in  the  St.  Louis  Medical  and  Surgical 
Journal  on  this  phase  of  the  topic.  He  is  disposed  to  regard 
the  fatal  affections  of  the  late  General  Grant  and  of  Napoleon 
I.  as  directly  dependent  on  the  complicating  reversal  of  busi- 
ness ventures  in  the  former  and  political  disaster  in  the  latter 
instance.  However,  he  is  frank  enough  to  say  that  his  mental 
theory  was  received  with  ridicule  by  some  of  the  profession 
and  with  disfavor  by  nearly  all. 

Later,  Rohe  has  written  in  the  Fhiladelpliia  Medical  Times, 
taking  a  position  similar  to  that  of  Hughes.  Kohler,  writing 
in  1853,  enunciates  sudden  and  persistent  grief  and  care  of 
all  kinds  as  apparently  justifiable  causes  for  cancer  in  many 
instances. 

Willard  Parker,  in  1875,  submitted  the  analysis  of  nearly  400 
cases  of  cancer  of  the  breast  in  women,  frequently  attributed 
to  the  mental  affection  as  an  exciting  cause.  In  fact,  he  reports 
that  "j^  of  the  cases  had  been  subject  to  much  mental  affection, 
care,  or  sorrow. 

Snow,  1893,  believes  that  of  all  the  causes  of  cancer,  neu- 
rotic agencies  are  the  most  powerful,  remarking  that  idiots  and 
lunatics  are  remarkably  exempt  from  this  infliction.  Snow 
cites  156  cases  in  which  he  regards  mental  depression  as  the 
dominating  cause  of  cancer.  In  support  of  this  is  quoted  the 
fact  of  the  rapid  evolution  of  cancer  in  Strasburg  after  the 
bombardment.  However,  another  reason  for  this  will  be  men- 
tioned later. 

Regarding  the  second  proposition,  viz. :  that  cancer  may  arise 
indirectly  from  mental  depression,  because  of  the  defective 
nutrition  attendant  upon  it,  Virchow,  writing  in  1867,  in  dis- 
cussing thoroughly  the  neuro-pathological  theory  of  the  origin 


48  BRYANT, 

of  tumors,  especially  of  cancer,  says  that  the  evidence  sub- 
mitted under  this  head  is  weak.  He  approves  of  the  idea  ad- 
vanced by  Barras,  that  these  mental  states  may  themselves  be 
a  part  of  the  prodromes  of  the  cancerous  disease.  He  further 
states  that  cancer  in  general,  and  cancer  of  the  stomach  in  par- 
ticular, is  more  common  in  the  well-to-do  than  in  the  indigent, 
so  that  one  might  conclude  that  the  more  nervous  class  of 
people  is  the  more  exposed  to  cancer.  This  explanation,  how- 
ever, is  very  problematic,  and  would  not  hold  good  for  tumors 
as  a  whole.  Beside,  a  weakness  of  the  nerves  does  not  imply 
a  weakness  in  general  nutrition. 

In  any  case,  the  influence  of  the  nerves  could  do  no  more 
than  lessen  the  vitality  of  the  tissues,  which  influence  would  be 
equally  apparent  in  other  disorders  of  nutrition,  and  could, 
therefore,  be  only  a  simply  predisposing  cause. 

It  seems  to  us  quite  probable  that  the  influence  of  mental 
disturbance  on  the  bloodvessels  and  in  the  nutrition  of  the 
parts  incident  to  the  bombardment  of  Strasburg  will  account 
much  more  rationally  for  the  evolution  of  cancer  thereafter  than 
fear  alone  can  do. 

Paget  (1865),  in  speaking  of  the  occurrence  of  cancer  from 
mental  distress,  expressed  the  belief  that  the  numerical  evidence 
to  uphold  such  a  view  is  lacking.  Nor  was  it  apparent  that  joy- 
ousness  and  prosperity  were  safeguards  against  cancer.  He  re- 
garded the  depressed  nutrition  incident  to  the  mental  state  as 
weighty  and  the  fatal  cause  of  cancer  development  in  these  cases. 

Picot  (1877)  regards  the  influence  on  the  nutrition  of  mental 
emotion  as  of  importance  in  the  outbreak  of  cancerous  disease 
in  those  predisposed  by  heredity  or  otherwise. 

Walshe  (1846),  in  opposing  the  neurotic  theory  of  cancer, 
points  out  the  facts  that  authors  who  dwell  most  strongly  on 
this  mode  of  formation  of  cancer,  curiously  enough  fix  on  the 
middle  ranks  of  society  as  those  furnishing  the  least  amount 
of  cancerous  disease,  yet  these  are  precisely  the  classes  in  which 
reverses  of  fortune  most  frequently  occur,  and  in  which  mental 
anxiety,  inseparable  as  it  is  from  professional  and  commercial 
pursuits,  must  be  strongest  and  most  constant. 


INFLUENCE    OF    MENTAL    DEPRESSION    ON     DISEASE.       49 

Luecke  and  Zahn  (1896)  regard  the  influence  of  mental  emo- 
tions as  operating  on  the  production  of  cancer  by  diminishing 
the  vitality  only  in  a  general  way. 

Fere,  in  his  recent  work  on  the  pathology  of  emotions  (1899), 
states  regarding  the  direct  effects  of  nervous  influence  on 
cancer,  that  observations  of  this  sort  are  rarely  of  satisfactory 
clearness  when  the  organ  involved  is  one  whose  destruction 
is  partial.  But  when  the  tumor  affects  the  brain,  it  is  not  very 
rare  to  see  explosion  of  the  pathognomonic  symptoms  pro- 
voked by  moral  emotion.  This  can  be  said  only  when  the 
emotion  acts,  not  upon  the  tumor,  but  upon  the  bloodvessels 
which  modify  the  volume. 

The  third  contention,  that  mental  depression  exercises  in  no 
respect  influences  in  the  causation  of  cancer  that  admit  of 
sufficient  proof  to  warrant  serious  scientific  discussion,  has 
many  powerful  and  gifted  advocates. 

Lebert,  writing  in  185 1,  says  substantially,  under  the  head  of 
etiology  of  cancer : 

The  influence  of  the  moral  agencies  in  the  production  of 
cancer  has  been  admitted  by  all  the  authors  who  have  written 
up  this  subject.  But  when  we  study  the  observations  on  which 
the  view  is  based  we  do  not  find  anything  beyond  impressions 
to  sustain  it.  He  had  investigated  a  large  number  of  cases  in 
regard  to  the  operation  of  this  cause,  but  had  found  propor- 
tionally very  few  in  which  intense  and  profound  vexation  had 
preceded  the  appearance  of  cancer.  On  the  contrary,  he  found  so 
many  patients  without  any  history  of  this  sort  that  he  could  not 
believe  the  occurrence  of  such  causes  was  anything  more  than 
coincidence.  He  referred  to  the  well-known  fact  that  cancer  is 
common  among  domestic  animals,  and  inquired  if  we  were  to 
regard  them  as  subjects  of  sorrow.  Finally,  he  said,  "  Nothing 
is  less  proven  than  the  influence  of  depressing  emotions  in  the 
etiology  of  cancer." 

Velpeau,  in  1858,  disapproved  of  the  influence  of  mental 
perturbation  in  the  following  strong  terms : 

"  However  much  invoked  by  the  public  as  causes  of  cancer, 
they  play  absolutely  no  part  in  its  production,  and  if  we  take 

Am  Surg  4 


50  BRYANT, 

such  things  into  account,  it  is  rather  to  humor  the  patient  than 
to  satisfy  a  scientific  argument." 

Birch-Hirschfeld  (1885)  places  the  subject  of  the  origin  of 
cancer  from  mental  distress  in  the  same  category  as  the  dietetic 
origin  ;  that  is  to  say,  the  question  of  "  such  etiology  does  not 
admit  of  scientific  discussion." 

Williams  (1894)  was  unable  to  concur  in  this  theory,  and 
stated  that  the  majority  of  cancer  patients  whose  life-history  he 
had  investigated  appeared  to  have  been  less  exposed  to  depress- 
ing influences  of  this  kind  than  most  women  of  corresponding 
age  in  the  general  population.  The  fact  that  Perls,  Billroth, 
Zeigler,  and  Lancereaux  make  no  mention  of  these  influences  in 
the  etiology  of  cancer  cannot  be  regarded  as  oversight,  but 
rather  as  a  silent  expression  of  their  belief  that  such  causes 
were  not  entitled  to  the  dignity  of  notice. 

We  have  quoted  more  extensively  than  we  had  intended  at 
the  outset,  but  justify  this  course  since  it  places  before  us  the 
consensus  of  able  opinions  and  incidentally  many  of  the  argu- 
ments employed  in  forming  them. 

As  will  be  noticed  from  the  statements  already  quoted,  the 
great  preponderance  of  scientific  opinion  favors  the  idea  that 
rnental  depression  at  the  most  exercises  only  a  predisposing 
influence  in  the  causation  of  cancer;  also,  that  this  influence  is 
the  natural  product  of  the* defective  nutrition  incident  to  the 
perturbation  itself. 

When  it  is  recalled  how  frequently  the  secondary  manifesta- 
tions following  operations  for  cancer  appear  to  be  facilitated, 
both  in  promptness  of  appearance  and  after  progress,  by 
increased  vulnerability,  due  to  imperfect  nutrition,  we  are  dis- 
posed to  favor  the  belief  that  impaired  nutrition  from  any  cause 
may  encourage  malignant  development. 

In  the  further  discussion  of  this  topic,  under  the  phase  that 
cancer  may  result  from  the  direct  influence  of  mental  depres- 
sion, it  appears  to  us  not  unwise  to  make  the  following  division 
of  this  class  of  cases:  i.  Cases  in  which  mental  depression  is 
not  associated  with  the  idea  of  cancer.  2.  Cases  in  which 
mental   depression  is   associated  with  the   idea  of  impending 


INFLUENCE    OF     MENTAL     DEPRESSION     ON     DISEASE.       5I 

cancer  of  primary  or  secondary  occurrence.  3.  Cases  in  which 
the  depression  is  the  outcome  of  common  causes. 

Regarding  it  as  reasonable  to  assume  that  if  mental  pertur- 
bation cause  malignant  disease,  malignant  diseases  should  char- 
acterize the  history  of  patients  suffering  from  the  effects  of 
mental  perturbation,  we  addressed  our  attention  to  the  history 
of  cases  of  melancholia. 

Inasmuch  as  mental  depression  from  all  causes  leads  to  mel- 
ancholia in  numerous  instances,  it  seemed  to  us  proper  to 
investigate  the  records  of  asylums  for  the  insane,  with  the 
view  of  ascertaining  (i)  the  number  of  admissions  for  melan- 
cholia and  the  cause  assigned  for  its  development :  also,  the 
death-rate  in  those  cases  from  malignant  disease ;  (2)  the  rela- 
tion to  malignant  diseases  of  the  death-rate  of  the  insane  and 
that  of  the  public  at  large. 

While  there  is  no  reason  to  believe,  nor  has  it  been  claimed, 
that  mental  depression  dependent  on  the  fear  of  impending 
cancer  is  more  potent  as  a  cause  than  are  the  common  pertur- 
bations of  everyday  life,  still  it  cannot  be  amiss  to  refer  to  the 
idea,  notwithstanding  the  fact  that  no  direct  kinship  can  exist 
between  any  peculiar  kind  of  mental  perturbation  and  its 
sequels ;  that  is,  the  fear  of  cancer  can  no  more  cause  it  than 
can  the  fear  of  tuberculosis. 

In  the  Nineteenth  Annual  Report  of  the  State  Hospital  for  the 
Insane,  at  Warren,  Pennsylvania,  the  following  interesting  facts 
bearing  on  the  causes  of  mental  depression  as  producing  insan- 
ity appear.  Only  those  of  fifteen  years  and  upward  are  admitted 
to  the  institution.  Anxiety  from  various  causes,  domestic  and 
financial  troubles,  unrequited  love,  etc.,  are  the  alleged  causes 
of  insanity  in  508  (ii-39  +  per  cent.)  of  the  admissions  during 
the  last  twenty  years.  It  appears  that  of  the  4458  admissions, 
745  (16.71  +  per  cent.)  of  the  number  suffered  from  melan- 
cholia, of  which  number  402  were  females  and  343  males.  Only 
5  (i  in  891)  of  the  entire  number  (4458)  died  from  malignant 
disease,  and  of  these  one,  a  male,  died  from  cancer  of  the 
stomach  ;  in  the  remainder,  the  females,  death  was  caused  in 
3  instances  by  cancer  of  the   breast,  and    in    i   of  the    liver. 


52  BRYANT, 

There  is  nothing  in  the  report  to  show  that  any  one  of  the  melan- 
cholic cases  died  from  cancer,  and  if  it  should  happen  that  all 
5  were  melancholic  cases,  then  the  death-rate  would  be  very- 
much  less  per  cent.  (0.67  -]-  of  i  per  cent.)  in  melancholia  from 
perturbation  than  it  now  appears  to  be  from  cancer  among  the 
people  at  large  (6.42  per  cent.). 

In  this  immediate  connection  it  is  important  to  note  the  sig- 
nificance of  the  following  summary,  prepared  for  me  a  few  days 
ago  by  Dr.  Roger  S.  Tracy,  the  eminent  statistician  of  the 
Health  Department  of  Greater  New  York.  The  computations 
of  Dr.  Tracy  show  the  following  comparative  relations  between 
the  total  death-rate  and  that  from  cancer  in  the  sexes  above 
fifteen  years  of  age  in  England  and  Wales,  Scotland,  Paris,  and 
New  York,  for  the  ten-year  period  of  1889  to  1898  inclusive: 

Ten  Years,  1889-1898  Inclusive. 

Great  Britain,  Paris,  and  Neio  York  Combined. 

Deaths  of  males,  total  and  from  cancer,  fifteen  years  and  upward. 

England  and  "Wales 

Scotland  ..... 

Paris      ...... 

New  York      ..... 

10.5,257  2,226,389 

Males  15  and  over.     Per  cent,  of  cancer  on  total,  4.73 

Deaths  of  females,  fifteen  years  old  and  upward,  for  ten  years,  1889-1898 

inclusive. 

Cancer.  Total  deaths. 

England  and  Wales        .         .         .134,106  1,597,092 

Scotland 17,986  253,650 

New  York 6,904  111,993 

Paris 15,928  176,236 


Cancer. 

Total  deaths. 

81,048 

1,667,011 

10,759 

227,485 

9,386 

200,144 

4,064 

131,749 

174,924  2,138,971 

Females  15  and  over.     Per  cent,  of  cancer  on  total,  8.18. 

Grand  Total. 


Cancer. 

Total  deaths. 

Per  ct.  of  cancer 
on  total. 

Males,      15  and  over 

105,2.57 

2,226,389 

4.73 

Females,   "     "      " 

174,924 

2,138,971 

8.18 

280,181  4,365,360  6.42 


INFLUENCE    OF    MENTAL     DEPRESSION     ON     DISEASE.       53 

The  meaning  of  these  figures  is  of  vital  consequence  in  more 
than  a  single  comparative  sense.  It  demonstrates  not  only  the 
relative  infrequency  of  cancer  in  insane  patients,  but  also  the 
startling  frequency  of  death  from  cancer  among  the  people  at 
large  ;  also  that  the  female  sex  suffers  from  cancer  nearly  twice 
as  frequently  as  the  male,  apparently  irrespective  of  any  partic- 
ular form  of  insanity. 

Prompted  by  the  results  of  the  general  statistical  outcome 
just  stated,  we  determined  to  investigate  along  a  special  line  of 
observation,  and,  with  this  purpose  in  view,  consulted  numer- 
ous annual  reports  of  insane  institutions  in  various  parts  of  the 
country. 

Unfortunately,  the  plans  of  compilation  of  these  institutions 
in  many  instances  were  entirely  devoid  of  any  practical  scien- 
tific outcome,  it  seemingly  being  regarded  as  more  important  to 
report  definitely  the  number  of  bushels  of  potatoes  eaten  than 
the  number  of  patients  cured.  It  may  not  be  impossible,  in 
many  institutions  dependent  upon  the  public  coffers  for  sup- 
port, that  political  expediency  is  regarded  a  more  potent  factor 
of  capacity  than  that  of  scientific  attainment. 

However,  we  collected  67,718  cases  of  insanity,  of  which 
15,031  (22  +  per  cent.)  were  of  the  melancholic  type.  Of  this 
number  53  +  per  cent,  were  male  and  46+  per  cent,  female 
melancholies,  showing  in  this  instance  an  excess  of  7  +  per 
cent,  of  the  male  sex.  The  deaths  from  cancer  (114)  in  the 
total  number  (67,718)  were  0.168  +  per  cent.,  a  rate  far  less 
than  that  of  the  general  public  (6.42  per  cent.).  Of  the  total 
number  of  deaths  from  cancer  (114)41  (36 —  per  cent.)  were 
males  and  73  (64  +  per  cent.)  were  of  the  female  sex.  There- 
fore, it  is  evident  that  nearly  two-thirds  of  the  total  number  of 
deaths  from  cancer  were  females,  although  less  than  one-half  of 
the  total  cases  of  melancholia  were  of  that  sex. 

With  the  idea  of  ascertaining  the  comparative  frequency  of 
cancer  of  the  sexes,  as  modified  by  the  effect  on  the  patients  of 
perturbing  mental  influences,  as  represented  by  the  cases  of 
melancholia,  the  records  of  the  male  and  female  departments  of 
the  Manhattan  State  Hospital  for  the  Insane  were,  through  the 


54 


BRYANT, 


courtesy  and  co-operation  of  the  efficient  superintendents,  Drs. 
MacDonald  and  Dent,  interrogated  for  a  period  of  ten  years 
following  1890.  Only  patients  above  15  years  of  age  are  con- 
sidered. 


Female  Department  of  Manhattan  State  Hospital  for  Insane. 
Cases  of  melancholia  admitted  since  1890. 


Year.               '^ 

0.  of  cases 

Died  of  malig- 

Died of  otlier 

admitted. 

nant  disease. 

diseases. 

Oct.  1,  1890,  to  Sept.  30,  1891     . 

326 

0 

59 

1892      . 

406 

1 

69 

1893      . 

431 

3 

84 

1894     . 

479 

2 

104 

1895     . 

581 

3 

101 

1896     . 

543 

0 

110 

1897     . 

344 

2 

81 

1898     . 

348 

3 

50 

1899     . 

296 

0 

49 

1900     . 

380 

4 

65 

4134 

18 

772 

Death-rate,  ^/j  -f-  of  1  per  cent,  in  ra 

elancholia 

Other  forms  of  insanity  since  1890. 


Year. 


No.  of  cases    Died  of  malig-    Died  of  other 


■ 

admitted. 

nant  disease. 

diseases 

Oct.  1,  1890,  to  Sept.  30,  1891     . 

368 

0 

106 

1892     . 

391 

3 

111 

1893     . 

402 

1 

209 

1894     . 

311 

0 

116 

1895     . 

388 

1 

124 

1896     . 

327 

0 

175 

1897     . 

418 

2 

159 

1898     . 

472 

0 

185 

1899     . 

427 

2 

170 

1900     . 

411 

1 

181 

3915  10  1536 

Death-rate,  V4  +  of  1  per  cent,  in  other  forms  of  insanity. 

It  will  be  noted  at  once  that  the  death-rate  from  cancer  in  the 
female  patients  suffering  from  melancholia  is  nearly  twice  as 
large  as  when  associated  with  other  forms  of  insanity  in  the 
same  sex. 


INFLUENCE    OF    MENTAL    DEPRESSION    ON     DISEASE.       55 

An  examination  of  the  males  for  the  same  period  revealed 
the  following  interesting  exhibit. 


Male  Department  of  Manhattan  State  Hospital  for  Insane. 
Cases  of  melancholia  admitted  since  1890. 


Year. 

Oct.  1,  1890,  to  Sept.  30,  1891 
1892 
1893 
1894 
1895 
1896 
1897 
1898 
1899 
1900 


No.  of  cases    Died  of  malig-    Diei]  of  other 


admitted. 

iiant  disease. 

diseases 

258 

0 

35 

372 

1 

47 

323 

0 

62 

244 

1 

54 

232 

1 

61 

346 

0 

63 

328 

1 

48 

309 

0 

30 

268 

1 

32 

339 

2 

34 

3019 


466 


Death-rate,  Vi  —  of  ^  P^^"  ^^^^-  i"  melancholic  patients. 

Other  forms  of  insanity  admitted  since  1890. 

Year  No.  of  cases    Died  of  malig-     Diedofotlier 

admitted.      nant  disease.         diseases. 


Oct.  1,  1890,  to  Sept.  30, 1891 

.  463 

1 

204 

1892 

.  442 

3 

238 

1893 

.  517 

0 

201 

1894 

.  408 

3 

229 

1895 

.  489 

1 

256 

1896 

.  486 

2 

281 

1897 

.  440 

0 

221 

1898 

.  439 

0 

258 

1899 

.  378 

0 

225 

1900 

.  332 

1 

235 

4394 


11 


2348 


Death-rate,  Vt  +  of  1  per  cent,  in  other  forms  of  insanity. 


It  appears  from  these  figures  that  melancholia  (^  —  of  i  per 
cent.)  in  the  male  exercises  no  distinctive  influence  on  the  death 
rate  as  compared  to  other  forms  of  insanity  {}(  -{-  of  i  per 
cent.). 

It  likewise  appears  (i)  that  the  various  forms  of  mental  per- 
turbation are  common  causes  of  tnelancholia,  and  that  the  male 
suffers  from  melancholia  from  these  causes  quite  as  frequently 
as  the  female ;  (2)  that  in  the  female  cancer  is  associated  with 


56       INFLUENCE    OF    MENTAL    DEPRESSION    ON     DISEASE. 

melancholia  (4  --  of  l  per  cent.)  about  twice  as  often  as  in  the 
male  (^  —  of  i  per  cent.),  also  nearly  twice  as  frequently  as  with 
"other  forms  of  insanity"  in  either  sex  {}(  -\-  of  i  per  cent.)  in 
each ;  (3)  and  to  repeat  that  cancer  in  the  male  is  not  practi- 
cally fatally  associated  with  melancholia  oftener  {}( —  of  i  per 
cent.)  than  with  other  forms  of  insanity  (^^  —  of  1  per  cent.). 
It  is,  consequently,  evident  that  for  some  reason  the  death-rate 
from  cancer  in  melancholia  in  female  cases  (f  -r  of  i  per  cent.) 
is  much  greater  than  in  the  opposite  sex  (5^  —  of  i  per  cent.). 

That  the  effect  of  mental  perturbation  is  potent  in  the  male 
is  evidenced  by  the  fact  that  melancholia  occurs  quite  as  often 
(page  51)  and  perhaps  oftener  (page  53)  for  this  reason  in  the 
male  as  in  the  female  sex.  However,  since  cancer  happens  in 
melancholic  cases  for  similar  reasons  as  frequently  again  in  the 
female  as  in  the  male  sex,  we  must  assume,  in  accounting  for 
this  difference,  the  presence  of  the  activity  of  special  reasons 
in  the  former,  which  are  no  part  of  the  history  of  the  latter  sex. 

Perhaps  the  vulnerability  incident  to  the  impoverishment  of 
the  blood  in  melancholia — a  condition  described  by  Steele  as 
constant  and  potent  in  these  cases — may  be  of  greater  measure 
or  profounder  significance  in  the  female  than  in  the  male  sex. 
And,  too,  the  more  extended  field  available  for  malignant  attack 
in  the  female  may  account  for  the  apparent  differences  in  the 
degree  of  infliction. 

At  all  events,  there  is  nothing  probable  in  the  aforegoing  to 
warrant  the  assumption  that  mental  depression  exercises  any 
influence  in  the  causation  of  cancer  except  through  the  blood 
impoverishment  which  almost  invariably  exists  in  melancholia 
(Steele),  a  change  which  appears  not  materially  to  influence  the 
outcome  in  the  male,  as  the  percentage  of  affliction  is  substan- 
tially alike  in  this  sex  in  all  forms  of  insanity.  Hence,  it  ap- 
pears that  the  preponderance  of  malignant  manifestations  in  the 
female  should  be  attributed  rather  to  the  broader  field  of  attack 
than  to  any  form  of  special  vulnerability. 


THE   CAUSE   OF   CANCER/ 


By  THOMAS  S.  CULLEN,  M.D., 

liALTIMORE. 


Being  interested  in  the  subject  of  cancer,  I  have  followed  the 
work  in  the  New  York  State  Laboratory  for  the  last  two  years, 
and  learned  with  interest  the  results  obtained  by  Dr.  Gaylord 
and  embodied  in  his  lecture  at  the  Johns  Hopkins  Hospital 
and  in  his  paper  in  the  American  Journal  of  the  Medical  Sciences 
for  May  of  this  year. 

In  order  to  prove  conclusively  that  a  given  organism  is  the 
cause  of  cancer  it  is  necessary: 

1.  To  find  or  isolate  the  organism. 

2.  To  produce  cancer  by  inoculating  the  organism  into  another 
body. 

3.  To  recover  the  organism  from  the  cancer  thus  produced. 

I  have  had  the  opportunity  of  examining  some  of  Dr.  Gay- 
lord's  specimens,  and  it  is  certain  that  the  nodules  he  produced 
in  the  guinea-pig's  lungs  are  cancer.  He,  however,  used  peri- 
toneal fluid  and  not  a  pure  culture  of  the  organism,  and  hence 
the  first  and  second  requisites  are  not  properly  fulfilled.  He 
cannot  exclude  the  possibility  of  cancer  cells  from  the  patient 
having  been  carried  over  in  the  fluid  to  the  guinea-pig,  and  it  is 
a  well-established  fact  that  cancer  cells  may  be  transplanted  and 
grow.  The  third  requirement  is  barely  touched  upon,  and  no 
proof  of  its  successful  accomplishment  is  adduced. 

On  page  5 1 1  of  the  journal  above  mentioned  he  speaks  of 
being  able  to  cultivate  his  germ  with  "  comparative  regularity," 
and  we  are  given  the  medium  upon  which   it  grows.     And  yet 

1  Discussion  of  Dr.  Park's  paper  on  "  The  Cause  of  Cancer." 


58  CULLEN, 

no  word  as  to  its  appearance  or  behavior  on  the  culture  medium 
is  mentioned.  Nor  have  we  a  picture  of  it,  although  both  Plim- 
mer's  and  Sanfelice's  organisms  are  depicted  on  Plate  VII. 
This  omission  is  difficult  to  account  for.  Further,  on  page  537, 
a  list  of  his  injections  into  animals  is  found,  and  here  also  we 
fail  to  find  a  single  instance  where  there  is  conclusive  evidence 
of  a  pure  culture  of  a  germ  being  employed. 

The  major  portion  of  the  article  is  taken  up  with  the  exam- 
ination of  tissues  hardened  according  to  different  methods;  but, 
as  Prof.  Welch  pointed  out  at  the  Hopkins  meeting,  we  might 
argue  indefinitely  upon  the  histological  changes  without  making 
an  iota  of  progress.  In  fact,  for  years  one  body  of  men  has 
been  claiming  that  these  peculiar  bodies  found  in  carcinoma  are 
due  to  cell  degeneration  ;  the  opposite  faction,  that  they  are 
parasites.  It  is  only  by  cultivating  the  organism,  if  there  be 
any,  and  then  producing  the  disease  afresh  with  this  newly- 
found  germ,  that  we  can  prove  the  cause  of  this  dread  malady. 
As  a  matter  of  fact,  Dr.  Gaylord  has  confirmed  the  results  of 
others,  but  added  little  or  nothing  new,^  and  the  cause  of  cancer 
is  still  an  unknown  factor.  It  is  very  unfortunate  that  the  sug- 
gestion that  cancer  parasites  were  floating  around  in  the  blood 
has  led  a  portion  of  the  daily  press  to  infer  that  cancer  is  a 
blood  disease  and  consequently  that  the  removal  of  a  cancer 
will  be  useless,  as  the  disease  is  sure  to  appear  at  another  point. 
Such  is  certainly  erroneous.  We  know  that  cancer  is  not  a 
blood  disease,  but  that  in  the  early  stages  it  is  an  entirely  local 
process ;  that  it  is  permanently  curable  is  evidenced  by  the  re- 
sults in  European  and,  to  come  nearer  home,  in  our  own  hos- 
pitals, where  patients  are  living  and  well  years  after  complete 
removal  of  the  growth. 

Dr.  Gaylord  and  his  associates  should  in  nowise  be  discour- 
aged. Many  of  the  world's  most  able  investigators  have  been 
seeking  the  same  goal,  and  as  yet  none  has  reached  it.  They 
should  be  encouraged  at  every  point,  as  in  their  love  for  science 

•  In  justice  to  Dr.  Gaylord,  it  must  be  added  that  the  above-mentioned  article  is 
a  preliminary  communication,  and  that  the  completed  work  may  solve  many  of  the  still 
obscure  points. 


THE    CAUSE    OF    CANCER.  59 

they  are  willing  to  forego  financial  prosperity  in  the  hope  that 
they  may  eventually  rid  mankind  of  this  scourge.  New  York 
State  is  to  be  congratulated  on  its  wisdom  in  establishing  a 
cancer  laboratory,  and  is  showing  a  commendable  spirit  in 
increasing  instead  of  diminishing  the  support  accorded  its 
scientific  men. 


Dr.  Park  (closing  the  discussion)  :  I  have  not  told  one-half  of  what 
I  would  like  to,  but  a  further  paper  will  be  prepared  by  Dr.  Gaylord, 
and  much  more  will  be  published  by  the  Buffalo  Laboratory  in  a  short 
time.  We  have  done  a  large  amount  of  inoculation  work,  but  all  the 
animals  have  died,  and  apparently  that  which  was  introduced  was  the 
cause  of  death.  We  are  not  yet  prepared  to  report  our  entire  expe- 
rience, but  expect  to  do  so  in  the  future. 


THE  CLINICAL  VALUE  OF  BLOOD  EXAMINATIONS 

IN  APPENDICITIS  :  A  STUDY  BASED  ON  THE 

EXAMINATION  OF  ONE  HUNDRED  AND 

EIGHTEEN  CASES  IN  THE  GERMAN 

HOSPITAL,  PHILADELPHIA. 

By  J.  C.  Da  COSTA,  Jr.,  M.D., 

PHILADELPHIA. 


Mr.  President  and  Fellows  of  the  American  Surgical 
Association  :  The  communication  which  I  have  the  honor  of 
presenting  to  the  Association,  by  the  invitation  of  your  Secre- 
tary, is  offered  with  no  slight  hesitancy,  for,  at  first  glance,  it 
must  seem  somewhat  needless  to  approach  a  topic  already  so 
familiar  to  all  surgeons,  thanks  largely  to  the  careful  studies 
made  by  Cabot  and  by  Greenough  during  the  past  five  years. 
Still,  there  are  reasons  which  appear  to  justify  a  further  consid- 
eration of  this  topic.  The  fact,  for  example,  that  certain  of  the 
blood  changes  in  appendicitis  have  been  either  overlooked  or 
regarded  as  trivial  in  comparison  with  other  more  conspicuous 
features  of  the  blood  picture,  and  the  tendency  of  some  clin- 
icians to  attach  undue  diagnostic  and  prognostic  significance  to 
the  blood  report — these  reasons,  perhaps,  are  of  sufficient 
weight  to  render  the  theme  less  hackneyed  than  its  title  leads 
one  to  infer. 

Methods  and  Technique.  The  conclusions  embraced  in  this 
report  are  based  upon  data  derived  from  the  examination  of 
1x8  cases  of  appendicitis  in  Dr.  John  B.  Deaver's  ward  at  the 
German  Hospital.  All  these  cases  were  treated  surgically,  and 
the  statistics  relating  to  the  blood  changes  represent  the  condi- 
tion of  the  blood  before  operation,  usually  at  the  time  imme- 
diately   after    the    patient's    admission    to    the    hospital.      The 


VALUE    OF    BLOOD    EXAMINATIONS    IN    APPENDICITIS.       6l 

majority  of  cases  were  examined  but  once,  and  in  the  few 
instances  in  which  multiple  estimates  were  made  the  data  of 
the  initial  examinations  only  were  included  in  the  analysis. 

Most  of  the  counts  were  made  by  various  members  of  the 
hospital's  house-staff,  a  few  by  myself.  The  services  of  Dr.  G.  P. 
Miiller,  senior  resident  pathologist  at  the  hospital,  in  tabulating 
and  classifying  the  clinical  histories  of  the  patients,  have  been 
invaluable 

The  hcEmoglobin  estimates  were  made  with  a  von  Fleischl 
haemometer,  which,  for  the  sake  of  greater  accuracy,  was  en- 
closed in  a  light-proof  box  provided  with  a  camera-tube  limit- 
ing the  observer's  field  of  vision  to  the  mixing-chamber  of  the 
instrument.  As  a  rule,  a  number  of  different  readings  were 
made  by  several  examiners,  and  the  average  of  the  figures  most 
closely  corresponding  taken  as  the  final  estimates. 

Both  the  erythrocytes  and  leucocytes  were  counted  with  the 
same  instrument,  a  Thoma-Zeiss  erythrocyte-pipette,  Toisson's 
solution  being  used  for  diluting  the  blood,  generally  in  the  pro- 
portion of  I  :  200.  Zappert's  counting-slide,  having  a  ruled 
surface  equalling  that  of  3600  of  the  small  squares  of  the  orig- 
inal Thoma-Zeiss  counting-cell,  was  employed  in  nearly  every 
instance.  The  erythrocytes  in  at  least  200,  and  the  leucocytes 
in  not  less  than  3600  of  these  small  squares,  were  counted,  to 
serve  as  a  basis  for  the  calculation  of  the  total  number  of  cells 
to  the  cubic  millimetre  of  undiluted  blood. 

Differential  counts  were  made  only  in  exceptional  instances  ;  in 
those,  for  example,  with  a  leucocytosis  in  which  the  symptoms 
did  not  suggest  appendicitis  as  a  factor  of  the  leucocyte 
increase.  An  absence  of  any  important  qualitative  change 
affecting  the  blood-cells  in  this  disease  was  thought  to  justify 
the  omission  of  differential  counting  as  a  routine  step  in  all 
cases  in  which  the  symptoms  were  definite.  In  those  instances 
in  which  the  percentages  of  the  different  forms  of  leucocytes 
were  calculated,  the  figures  represent  the  average  of  counts  of 
at  least  250  cells,  made  from  heat-fixed  films,  stained  with 
Ehrlich's  triple  stain,  containing  acid  fuchsin,  methyl-green, 
and  orange-G. 


62  DACOSTA, 

Classification.  From  a  hjtmatological  view-point  all  forms 
of  appendicitis  may  be  conveniently  classified  in  two  general 
groups,  purulent  and  non-purulent.  The  first  group  includes 
simple  catarrhal  and  interstitial  inflammations  of  the  organ, 
unattended  by  abscess  formation,  by  gangrene,  and  by  general 
peritonitis,  singly  or  combined.  The  second  group  comprises 
cases  with  foci  resident  in,  or  primarily  arising  from,  the  appen- 
dix, with  or  without  a  complicating  appendicular  gangrene  and 
general  peritoneal  inflammation.  It  must  be  admitted  that 
such  a  vague  classification  as  this  is  useful  only  in  so  far  as  it 
relates  to  the  blood  changes  to  be  detected  by  routine  clinical 
examinations — changes  by  the  aid  of  which  the  surgeon  en- 
deavors to  determine  the  presence  or  absence  of  suppuration 
and  peritonitis,  and  to  trace  the  progress  of  the  lesion  from  day 
to  day. 

Of  the  ii8  cases  included  in  this  report,  38  (or  32.2  percent.) 
were  unattended  by  pus  formation,  while  in  the  remaining  80 
(or  d"]."]  per  cent.)  this  condition  prevailed,  sometimes  with  and 
sometimes  without  further  inflammatory  changes.  These  fig- 
ures, of  course,  do  not  represent  the  usual  ratio  between  the 
two  forms  of  the  disease  just  specified,  since  the  cases  here 
collected  were  not  examined  in  an  unbroken,  consecutive 
series. 

The  features  of  the  blood  changes  of  greatest  clinical  interest 
in  this  disease  are  the  anaemia  by  which  it  may  be  accompanied 
and  the  behavior  of  the  leucocytes,  the  former  being  sometimes 
so  decided  as  to  constitute  a  symptom  demanding  recognition 
and  serious  consideration,  and  the  latter  being  of  prime  in- 
terest in  relation  to  the  diagnosis  and  prognosis  of  the  attack. 

The  Anemia  of  Appendicitis.  Apparently  most  writers 
regard  this  subject  as  one  of  comparatively  trivial  importance, 
for  beyond  the  general  observation  that  in  chronic  cases,  pre- 
sumably septic,  a  variable  decrease  in  the  haemoglobin  percent- 
age and  in  the  number  of  erythrocytes  may  occur,  the  question 
thus  far  has  been  dismissed  with  but  casual  notice.  The  fact, 
however,  should  not  be  ignored  that  the  associated  anremia  may 
be   so   marked  as  to  constitute  a  symptom  demanding  careful 


VALUE    OF    BLOOD    EXAMINATIONS     IN    APPENDICITIS.       63 

attention,  even  should  it  not  be  of  sufficient  gravity  to  retard 
convalescence  or  to  endanger  the  patient's  life. 

(a)  HcBmoglobin.  Practically  every  case  of  appendicitis,  what- 
ever its  character,  shows  a  variable  degree  of  hiL-moglobin  loss, 
this  decrease  occurring  with  about  equal  frequency  in  both  the 
catarrhal  and  the  suppurative  forms  of  the  disease,  although  in 
the  latter  it  tends  to  become  more  striking  in  the  individual  case. 
Speaking  in  averages,  it  will  be  found  that  the  hii^moglobin  is 
diminished  to  at  least  one-half  of  the  normal  standard  in  ap- 
proximately I  case  in  every  lo  (lO. i  per  cent.),  while  in  an 
occasional  instance  it  falls  to  a  figure  which  operators  are 
accustomed  to  regard  as  perilously  low — to  40  per  cent,  or  less 
in  about  3  cases  (2.5  per  cent.)  out  of  every  100.  The  fact  that 
such  low  figures  are  encountered,  although  but  rarely,  seems 
sufficient  to  call  for  a  routine  haemoglobin  test  in  all  patients  to 
be  treated  surgically,  for  should  the  surgeon  meet  with  such  a 
profound  oligochromaemia  in  one  whose  other  symptoms  de- 
mand the  use  of  the  knife,  the  advisability  of  an  operation, 
unless  imperatively  indicated,  might  appear  to  him  question- 
able. Not  being  a  surgeon,  I  cannot  presume  to  discuss  this 
technical  point,  but  simply  draw  attention  to  the  fact  as  sug- 
gestive if  not  really  important.  It  may  be  added  that,  judging 
from  the  meagre  data  at  my  command,  an  extreme  haemoglobin 
loss  does  not  appear  per  se  to  be  dangerous,  since  uninter- 
rupted recovery  took  place  in  all  the  three  patients  of  this 
series  in  whom  hsemoglobin  readings  of  40  per  cent,  or  lower 
were  made.  Positive  conclusions,  however,  are  scarcely  justifia- 
ble from  so  small  a  number  of  examinations.  Judging  from  this 
series,  the  average  hccmoglobin  loss  in  all  forms  of  appendicitis 
is  about  30  per  cent.,  the  average  readings  for  the  118  cases 
being  70.1  per  cent,  of  normal,  or  69.1  per  cent,  for  the  catar- 
rhal, and  70.1  per  cent,  for  the  suppurative  form. 

{b)  Erythrocytes.  The  erythrocyte  loss,  save  in  exceptional 
instances,  is  inconspicuous,  since  in  fully  3  out  of  every  5  cases 
(or  in  63.5  per  cent.)  the  number  of  these  cells  ranges  between 
4,000,000  and  5,000,000  to  the  cubic  millimetre,  while  the  latter 
count   is  exceeded   in   about    i    case   in  every  10  (or  in    12  per 


64  DA   COSTA, 

cent.).  The  average  loss  for  the  38  catarrhal  cases  was  16.2 
per  cent,  (average  count,  4,186,846),  and  for  the  80  suppurative 
cases,  1 1.9  per  cent,  (average  count,  4,400,145),  while  the  most 
striking  examples  of  oligocythaemia  in  the  individual  case 
were  practically  equal  in  both  forms — 59  per  cent,  decrease  in 
the  non-suppurative  and  58  per  cent,  loss  in  the  suppurative, 
figures  corresponding  to  counts  of  2,050,000  and  2,100,000  per 
cubic  millimetre  respectively. 

These  results  tend  to  show  that,  contrary  to  the  current  view, 
patients  suffering  from  catarrhal  appendicitis  may  be  found  to 
be  anemic  just  as  frequently  as  those  suffering  from  forms  of 
the  disease  associated  with  abscess  formation  and  easily  recog- 
nized symptoms  of  septicaemia — a  characteristic  with  which  I 
have  been  frequently  impressed  long  before  this  attempt  was 
made  to  analyze  the  statistics  of  the  blood-counts.  Perhaps  the 
fact  that  the  majority  of  these  non-suppurative  appendicitides 
were  of  chronic  character,  occurring  in  patients  whose  consti- 
tutions, undermined  for  a  long  period,  were  greatly  debilitated, 
may  serve  to  explain  the  frequency  of  anaemia  in  this  variety 
of  the  disease.  Thus  it  appears  that  this  factor  of  inadequate 
blood  production  is  quite  as  active  in  provoking  anaemia  as  is 
the  element  of  sepsis,  which  is  largely  responsible  for  the  blood 
destruction  in  suppurative  appendicitis. 

(c)  Color  Index.  The  color  index,  or  the  figure  used  to  indi- 
cate the  richness  in  haemoglobin  of  the  individual  erythrocyte, 
is  usually  found  to  be  moderately  subnormal,  from  about  0.70 
to  0.80  in  the  great  majority  of  counts.  The  index  for  the 
total  118  cases  of  this  series  averaged  0.82  +,or  about  eighteen 
points  below  the  arbitrary  standard,  1  ;  in  the  38  non-sup- 
purative cases  it  was  0.82,  and  in  the  80  with  abscess,  0.79. 
The  foregoing  data  apply,  of  course,  only  to  averages,  but  they 
tend  to  show  that  an  anaemia  of  the  ordinary  secondary  type 
prevails  in  appendicitis — that  is,  one  in  which  the  haemoglobin 
loss  is  usually  somewhat  relatively  greater  than  that  of  the 
corpuscles.  In  the  individual  case,  however,  the  index  may  fall 
to  quite  as  low  a  figure  as  that  commonly  found  in  chlorosis,  to 
0.53,  in  one  of  these  cases,  for  example;  or,  on  the  other  hand, 


VALUE    OF    BLOOD    EXAMINATIONS    IN    APPENDICITIS.       6  = 


it  may  rise  to  as  high  a  figure  as  that  which  prevails  in  typical 
pernicious  an;L'mia,  to  1.50  in  another  case  in  the  series,  for 
instance. 

In  cases  with  severe  anitrnia,  deformities  of  shape  and  size 
were  commonly  noted,  but  neither  nucleated  erythrocytes  nor 
decided  evidences  of  atypical  staining  were  observed.  The 
number  of  stained  specimens  examined,  however,  was  too  small 
to  attach  to  these  remarks  any  value  regarding  the  occurrence 
of  erythroblasts  and  of  polychromatophilic  cells.  There  is  no 
good  reason  why  both  should  not  be  found  in  cases  in  which 
the  antX^mia  is  of  suf^ciently  grave  type.  The  range  of  the 
haemoglobin  and  erythrocytes  is  illustrated  by  the  following 
table  : 

Table  I. — Hemoglobin  and  Erythrocytes. 


Haemoglobin, 
percentage. 

Simple  catarrhal  and  interstitial 

forms. 

(38  cases.) 

Cases  with  abscess,  gangrene,  or 

general  peritonitis. 

(80  cases.) 

Acute. 

Chronic. . 

Total. 

Acute. 

Chronic. 

Total. 

Above  100  per  ct. 
90  to  100      " 
80  "    90      " 
70  "    80       " 
60  "    70       " 
50  "     60       " 
40  "    50       " 
30  '•     40       " 

1 
0 
3 
4 
3 
5 
2 
0 

0 
0 
6 
5 
8 
1 
0 
0 

1 
0 
9 
9 
11 
6 
2 
0 

0 
4 
14 
26 
17 
6 
6 
3 

0 
0 
3 
0 
0 
0 
1 
0 

0 
4 
17 
26 
17 
6 
7 
3 

Highest, 

Lowest, 

Average, 

102  per  ct. 
45        " 
69 

86  per  ct. 
60        " 
72.7     " 

102  per  ct. 
45 
69.1     " 

98  per  ct. 
:h8 

71.7     " 

90  per  ct. 

48 
76 

98  per  Ct. 
38        " 
70.1     " 

Erythrocytes, 
per  c.  mm. 

Above  5,000,000 
4,000,000-5,000,000 
3,000,000-1,000,000 
2,000,000-3,000,000 

1 
10 
6 

1 

3 
13 
4 

0 

4 
23 
10 

1 

9 
50 
12 

5 

2 
2 
0 
0 

n 

52 
12 
5 

Highest, 
Lowest, 
Average. 

5,660,000 
2,050,000 
4,240,389 

5,620.000 
3,100,000 
•4.348,000 

5.660,000 
2,050,000 
4,186,846 

5,710,000 
2,100,000 
4,372,500 

5,240,000 
4,490,000 
4,925,000 

5,710,000 
2,100,000 
4,400.125 

The  Range  OF  THE  Leucocytes.  The  numerical  fluctuations 
of  the  leucocytes  constitute,  by  all  odds,  the  most  important 
feature  of  the  blood  picture  associated  with  this  disease,  and 
the  behavior  of  these  cells  has  been  regarded  as  a  sign,  both  of 
diagnostic  and  of  prognostic  value,  to  interpret  with  more  or 
less  accuracy  the  pathological  condition  of  the  local  lesion  and 

Am  Surg  5 


66  D  A  C  O  S  T  A  , 

to  furnish  information  as  to  the  presence  or  absence  of  com- 
plications. To  what  extent  the  leucocyte-count  can  be  relied 
upon  as  a  dependable  clinical  sign  and  to  what  extent  it  may 
prove  misleading  in  routine  clinical  work  I  have  attempted  to 
determine  by  the  following  inquiry. 

In  the  catarrhal  and  interstitial  forms  of  appendicitis,  without 
abscess  or  any  of  its  consequences,  the  number  of  leucocytes,  as 
a  rule,  does  not  exceed  the  maximum  normal  standard  (10,000 
per  cubic  millimetre),  and,  indeed,  is  not  infrequently  much 
below  this  figure.  In  a  fairly  large  proportion  of  cases,  how- 
ever, exceptions  to  this  rule  must  be  noted,  for  counts  of 
12,000,  15,000  or.  rarely,  even  higher  may  sometimes  be  en- 
countered. In  the  present  series,  39.4  per  cent,  of  the  cases 
(15  cases)  showed  a  leucocyte  increase  ranging  between  10,000 
and  17.100,  the  latter  being  the  maximum,  while  in  60.5  per 
cent.  (23  cases)  the  counts  were  below  10,000,  the  minimum 
estimate  being  1600.  It  may  be  observed,  in  passing,  that  the 
maximum  count  of  the  individual  case  of  catarrhal  appendicitis 
is  somewhat  lower  than  the  average  count  in  the  purulent 
variety,  to  be  considered  later. 

It  does  not  seem  unreasonable  to  attribute  the  majority  of 
these  high  counts  to  the  presence  of  a  local  non-purulent  in- 
flammation restricted  to  the  peritoneal  covering  of  the  appendix, 
since  a  circumscribed  peritonitis  of  this  sort  is  not  uncommon 
in  this  form  of  the  disease,  and  is  quite  sufficient  to  account  for  a 
moderate  leucocytosis.  In  other  cases  the  possibility  that  the 
increase  represents  simply  a  blood-finding  of  the  associated 
anaemia  must  naturally  be  suggested,  or,  again,  that  it  may  be 
the  result  of  blood  inspissation,  for  the  production  of  which 
copious  emesis  or  purging  may  have  been  the  factors. 

In  cases  with  abscess,  gangrene,  or  general  peritonitis,  a  well- 
marked  leucocytosis  is  found  in  most  instances,  the  majority  of 
appendicular  abscesses  raising  the  count  to  15,000  or  20,000  per 
cubic  millimetre,  and  sometimes  to  even  a  higher  figure.  It  is, 
however,  a  well- recognized  fact  that  should  the  pus  focus  hap- 
pen to  be  so  effectually  walled  off"  that  little  or  no  absorption  of 
toxic  material  can  occur,  such  a  decided  increase  may  fail  to 
develop.     On  the  other  hand,  leucocytosis  may  also  be  absent, 


VALUE    OF     BLOOD    EXAMINATIONS    IN    APPENDICITIS, 


67 


or,  indeed,  leukopenia  may  be  found,  in  profoundly  septic 
patients  in  whom  the  effects  of  the  poison  have  proved  so 
crippling  that  reaction  is  stifled.  However  active  may  have 
been  this  factor  in  the  experience  of  others,  in  my  own  experi- 
ence it  has  rarely  been  found  that  the  patient's  resisting  powers 
were  so  effectually  overcome  that  leucocytosis  was  prevented, 
for  in  only  two  out  of  my  12  fatal  cases  (or  in  16.6  per  cent.) 
was  a  well-defined  leucocytosis  absent,  the  counts  in  these  two 
cases  being  6000  and  11,200  respectively.  In  the  other  ten 
counts  the  number  of  leucocytes  ranged  from  a  minimum  of 
14,200  to  a  maximum  of  58,500,  and  averaged  19,400  per  cubic 
millimetre. 

Table  II. — Fatal  Cases. 


No. 

Haemoglobin. 

Erythrocytes. 

Leucocytes. 

11,200 

Remarks. 

1 

71 

4,580,000 

2 

98 

5,420,000 

14,600 

36  hours  after  operation. 

98 

5,460,000 

10,200 

6  days       "           " 

96 

5,430,000 

16,800 

9    " 

"3 

88 

5,280,000 

58,500 

4 

100 

5,120,000 

15,200 

General  peritonitis. 

5 

85 

4,370,C00 

22,800 

6 

75 

4,550,000 

16,000 

7 

68 

4,470.000 

19,600 

8 

79 

3,840,000 

21,500 

9 

5,000,000 

6,000 

10 

95 

4,110,000 

14,200 

Immediately  alter  operation. 

90 

4,150,000 

20,400 

1  day  after  operation. 

ii 

75 

4,970,000 

14,800 

12 

46 

2,760,000 

11,600 

From  the  above  statements  it  is  natural  to  infer  that  the  degree 
of  leucocytosis,  as  determined  by  a  single  examination,  cannot  be 
relied  upon  as  a  prognostic  sign.  If,  however,  by  repeated  ex- 
aminations a  progressive  increase  in  the  number  of  leucocytes 
is  detected,  it  may  generally  be  concluded  that  the  pus  collec- 
tion has  become  more  extensive  or  that  a  general  peritonitis  has 
been  excited.  Such  accidents  as  these  were  heralded  in  three 
cases  of  this  series  by  an  increase  varying  from  6600  to  14,000 
cells  to  the  cubic  millimetre  in  excess  of  the  number  previously 
counted.  Perforation  is  usually  accompanied  by  an  abrupt 
rise  in  the  leucocytes,  although  it  is  to  be  recalled  that  in 
greatly  debilitated  individuals  this  increase  may  be  absent,  or 
indeed,  a  sudden  decrease  may  occur.  Personally,  I  have  not 
investigated  this  question  with  sufficient  thoroughness  to  war- 


68  DA   COSTA, 

rant  definite   conclusions  as  to  the  behavior  of  the  leucocytes 
under  these  circumstances. 

Absence  of  leucocytosis  has  also  been  observed  in  cases  in 
which  the  pus  focus  is  of  small  extent,  but  small  abscesses  are  by 
no  means  always  associated  with  low  counts,  for  the  intensity  of 
the  systemic  reaction  provoked  by  the  abscess,  and  not  the  ex- 
tent of  the  latter,  appears  to  be  the  more  active  determining 
factor  of  the  increase. 

In  the  present  series  the  count  for  purulent  cases  averaged 
17,453,  or  somewhat  less  than  double  the  average  figure  for  the 
catarrhal  variety.  The  leucocytes  were  in  excess  of  15,000  per 
cubic  millimetre  in  62.5  per  cent.,  or  fifty  of  the  counts,  and 
in  excess  of  20,000  in  25  per  cent.,  or  twenty  counts,  reach- 
ing a  maximum  of  58,500  in  a  single  instance.  In  37.5  per  cent., 
or  thirty  counts,  the  number  of  cells  was  below  1 5 ,000,  the  lowest 
estimate  being  6000. 

In  the  few  cases  with  leucocytosis  in  which  differential  counts 
were  made  it  was  found  that  the  increase  was  due  chiefly  to  a 
decided  absolute  and  relative  increase  in  the  polynuclear  neutro- 
phils, the  lymphocytes,  large  mononuclear  forms,  and  eosino- 
philes  being  relatively  diminished.  Neither  myelocytes  nor 
basophilic  leucocytes  were  observed  in  any  of  the  examinations. 

The  following  table  represents  the  range  of  the  leucocytes  in 
the  118  cases  examined: 

Table  III. — Leucocytes. 


Simple  catarrhal  and  interstitial 

Cases  with  abscess,  gangrene,  or 

forms. 

general  peritonitis. 

Leucocytes 

(38  cases.) 

(80  cases.) 

per  c.  mm. 

Acute. 

Chronic. 
0 

Total. 

Acute. 

Chronic. 

Total. 

Above  50,000 

0 

0 

1 

0 

1 

40,000-50,000 

0 

0 

0 

0 

0 

0 

35,000-40,000 

0 

0 

0 

2 

0 

2 

30,000-35.000 

0 

0 

0 

0 

0 

0 

25,000-30,000 

0 

0 

0 

3 

0 

3 

20,000-25,000 

0 

0 

0 

14 

0 

14 

15,000-20,000 

4 

0 

4 

30 

0 

30 

10,000-15.000 

2 

9 

11 

19 

3 

22 

5,000-10,000 

8 

9 

17 

7 

1 

8 

Below  5,000 

4 

2 

6 

0 

0 

0 

Highest, 

17,100 

15.000 

17,100 

5S,500 

14,009 

58,500 

Lowest, 

l.fiOO 

2,400 

l.fiOO 

0,000 

8,800 

0,000 

Average, 

9,124 

9,190 

9,158 

17,718 

12,425 

17.453 

VALUE    OF    BLOOD    EXAMINATIONS    IN     APPENDICITIS.       69 

To  recapitulate,  an  analysis  of  the  foregoing  data  warants 
the  following  conclusions  : 

1.  The  average  case  of  appendicitis  before  operation  shows  a 
loss  of  about  30  per  cent,  of  hremoglobin  and  of  more  than  half 
a  million  erythrocytes  per  cubic  millimetre.  Occasionally  the 
anaemia  is  of  a  grade  so  high  that  it  appears  to  constitute  in  itself 
a  serious  complication  and  to  raise  a  doubt  as  to  the  safety  of 
surgical  interference,  should  the  latter  otherwise  be  indicated. 
Doubts  on  this  score,  however,  have  not  been  justified  by  the 
records  of  the  cases  included  in  this  series. 

2.  Leucocytosis  may  occur  both  in  the  absence  and  in  the 
presence  of  an  abscess  and  its  consequences.  It  accompanies 
about  35  per  cent,  of  non-purulent  and  90  per  cent,  of  purulent 
cases. 

3.  Leucocyte  counts  ranging  between  10,000  and  15,000  or 
17,000  cannot  be  depended  upon  to  reflect  the  nature  of  the 
local  lesion,  since  this  degree  of  increase  may  be  found  both  in 
mild  catarrhal  and  in  purulent  cases.  Counts  of  20,000  or 
more  invariably  indicate  the  presence  of  pus,  gangrene,  or 
general  peritonitis,  one  or  all. 

4.  Leucocytosis  may  be  absent  both  in  trivial  catarrhal 
and  in  fulminant  cases  as  well  as  in  forms  of  circumscribed 
abscess. 

5.  In  operative  cases,  thorough  evacuation  of  the  abscess  is 
followed  within  a  few  days  by  a  decline  to  normal  in  the  num- 
ber of  leucocytes,  provided  that  the  recovery  of  the  patient  is 
uneventful.  Persistence  of  a  leucocytosis  after  the  third  or 
fourth  day  following  the  operation  may  usually  be  attributed 
either  to  undrained  pus  pockets,  to  general  peritonitis,  or  to 
both  of  these  factors. 

Value  of  the  Blood  Changes  as  Diagnostic  and  Prog- 
nostic Signs.  It  is  obvious  that  a  decided  increase  in  the 
number  of  leucocytes,  if  correlated  with  other  clinical  symptoms, 
may  serve  as  a  diagnostic  sign  of  definite  value.  On  the  other 
hand,  the  fact  cannot  be  emphasized  too  forcibly  that  an 
absence  of  leucocytosis,  except  in  conspicuously  septic  patients, 
signifies  nothing  definite. 


JO  DACOSTA. 

Regarding  a  leucocytosis  of  20,000  or  higher  as  a  certain  in- 
dication of  pus  or  its  consequences,  in  my  experience  in  one 
out  of  every  four  cases  of  appendicular  abscess  the  diagnosis  is 
justified  by  the  behavior  of  the  leucocytes.  This  may  seem  a 
most  conservative  estimate  of  the  value  of  the  leucocyte-count 
in  recognizing  such  a  condition,  and  its  acceptance  certainly 
restricts  the  utility  of  the  blood-count  as  a  diagnostic  aid,  but 
repeated  observations  have  proved  that  a  leucocytosis  of  less 
than  20,000,  or  at  the  minimum  17,000,  cannot  be  relied  upon 
as  a  trustworthy  sign  of  pus,  although,  as  already  pointed  out, 
pus  may  exist  with  much  lower  leucocytosis. 

In  a  patient  unmistakably  septic,  absence  of  leucocytosis 
should  be  interpreted  as  a  sign  of  an  intense  infection,  the 
prognosis  of  which  is  more  likely  grave  than  favorable.  A 
high  leucocytosis  in  such  instances  does  not  necessarily  in- 
dicate a  favorable  prognosis,  but  simply  represents  an  intense 
infection  coupled  with  normally  active  resisting  powers  on  the 
part  of  the  patient. 

Absence  of  leucocytosis  in  a  patient  with  mild  indefinite 
symptoms  is  a  clinical  sign  of  no  tangible  value  in  so  far  as  it 
may  serve  in  detecting  the  presence  of  pus,  since  a  large 
abscess  if  thoroughly  circumscribed  may  exist  without  causing 
the  slightest  increase  in  the  number  of  leucocytes. 

In  cases  treated  surgically  the  adoption  of  daily  leucocyte 
counting  as  a  routine  procedure  during  the  first  week  after  the 
operation  furnishes  the  surgeon  with  definite  information  re- 
garding the  progress  of  the  case,  since  the  advent  of  complica- 
tions or  the  failure  to  secure  complete  evacuation  of  pus  foci 
may  be  detected  by  the  persistence  of  or  an  increase  in  the 
leucocytosis. 

Unfortunately,  it  happens  that  just  those  conditions  which 
bear  the  closest  resemblance  to  appendicitis  as  a  rule  give  rise 
to  blood  changes  identical  with  those  found  in  the  latter  dis- 
ease, so  that  the  value  of  the  blood-count  as  a  means  of  differ- 
ential diagnosis  is  greatly  limited.  Thus,  leucocytosis  is  the 
rule  in  such  conditions  as  oiiarian  abscess,  pyosalpinx^  ectopic 
pregnancy,  perinephritic  abscess,  hepatic  abscess,  empyema  of  the 


VALUE    OF    BLOOD    EXAMINATIONS     IN    APPENDICITIS.       7I 

gallbladder,  and  malignant  disease  of  the  ccBcuni,  all  of  which 
have  been  confused  with  appendicitis.  Such  a  large  proportion 
oi  renal  and  hepatic  colics  are  associated  with  inflammatory  com- 
plications that  neither  of  these  conditions  can  be  distinguished 
with  any  degree  of  confidence  from  appendicitis  simply  by  the 
examination  of  the  blood.  Acute  gastritis  is  sometimes  accom- 
panied by  a  well-marked  leucocytosis,  and  sometimes  by  none 
at  all,  so  that  the  blood-count  cannot  be  relied  upon  as  a  clue 
in  distinguishing  this  disease  from  appendicitis.  The  same  is 
true  of  dysmeiiorrhoea,  in  which  disease  uterine  inflammatory 
changes  may  be  the  factor  of  a  leucocyte  increase.  Should  the 
diagnosis  lie  between  appendicitis  and  enteric  fever  the  former 
is  suggested  by  the  presence  of  a  leucocytosis,  since  this  sign 
practically  never  occurs  in  typhoid,  except  in  the  event  of  some 
obvious  complication,  such  as  hemorrhage  from  the  bowel  or 
perforation. 

In  doubtful  cases  a  leucocytosis  is  sufficient  to  exclude  such 
non-inflammatory  lesions  as  simple  enteralgia,  lead  colic,  ovarian 
neuralgia,  an  ovarian  cyst,  and  a  movable  kidney. 


THE  BLOOD  CHANGES   INDUCED  BY  THE  ADMIN- 
ISTRATION OF  ETHER  AS  AN  ANESTHETIC. 

By  JOHN    CHALMERS  Da  COSTA,  M.D., 

AND 

FREDERICK  J.  KALTEYER,  M.D., 

PHILADELPHIA. 
(y4  Contribiition  from  the  Laboratories  of  the  Jefferson  Medical  College  Hospital.') 


Many  years  ago  it  was  asserted  that  the  administration  of  an 
ansesthetic  has  a  destructive  influence  upon  the  blood.  This 
view  was  a  mere  opinion,  and  was  not  deduced  from  well- 
conceived  and  carefully  performed  experiments. 

Dr.  John  Snow  believed  and  taught  that  an  anaesthetic  agent 
suspends  the  processes  of  oxidation,  and  that  the  essence  of  the 
anaesthetic  state  is  suspended  oxidation.  This  view  has  been 
advocated  in  modern  times  by  Richardson,  but  has  of  late  been 
entirely  overthrown  by  a  recognition  of  the  facts,  stated  by 
Buxton,  that  we  can  produce  anaesthesia  by  hyperoxidation, 
and  that  a  number  of  "  deoxidizing  bodies  "  are  not  anaesthetics. 

In  i86i  Sansom  made  a  report  to  the  Royal  Medico-Chirurgi- 
cal  Society,  in  which  he  maintained  that  during  anaesthesia 
quantities  of  blood-corpuscles  are  destroyed.  He  did  not  ex- 
amine the  blood  before,  during,  and  after  anttsthesia,  but  made 
experiments  upon  blood  in  test-tubes  by  adding  to  it  anaesthetic 
drugs.  He  found  that  the  addition  of  an  anaesthetic  to  blood 
outside  of  the  body  destroys  the  corpuscles  and  liberates  color- 
ing matter.  The  above  method  was,  of  course,  inconclusive, 
could  give  no  positive  information,  and  was,  at  most,  merely 
suggestive. 


BLOOD    CHANGES     INDUCED     BY     ETHER.  73 

In  1869  Dr.  J.  H.  McQuillen'  made  a  series  of  experiments 
in  order  to  determine  the  condition  of  the  corpuscles  of  the 
blood  during  the  an;usthetic  state.  He  examined  the  blood  of 
a  number  of  human  beings  prior  to  and  after  the  administration 
of  ether,  chloroform,  and  nitrous  oxide,  and  stated  that  he  found 
no  evidence  of  corpuscular  destruction. 

In  1890  Mikulicz^  presented  the  studies  of  a  pupil,  Bierfreund, 
in  regard  to  the  amount  of  haemoglobin  in  the  blood  in  surgical 
diseases,  with  special  reference  to  its  restoration  after  the  oc- 
currence of  hemorrhage.  He  was  the  first  to  observe  that  the 
administration  of  chloroform  may  reduce  the  haemoglobin  from 
5  to  10  per  cent. 

In  1893  Garrett  and  Oliver,'^  performed  numerous  experiments 
and  arrived  at  the  conclusion  that  anaesthetics,  particularly 
chloroform.,  deoxidize  the  blood  and  also  the  tissues,  and  thus 
induce  malnutrition  and  the  formation  of  quantities  of  waste 
products,  the  elimination  of  these  toxic  products  causing  a 
severe  and  possibly  dangerous,  or  even  a  fatal,  strain  upon  the 
excretory  glands.  Garrett  and  Oliver  also  pointed  out  the  fact 
that  a  patient  under  the  influence  of  ether  sweats  profusely,  a 
process  which  lowers  the  temperature,  the  temperature  being 
also  lowered  by  the  evaporation  of  ether  and  by  depression  of 
the  nervous  system. 

In  this  paper  we  point  out  that  the  sweating  which  occurs 
under  ether  must  be  taken  into  consideration  in  estimating 
blood  changes. 

In  1895  one  of  us  (J.  Chalmers  Da  Costa)  made  an  investiga- 
tion of  the  action  of  ether  upon  the  blood,  he  being  at  that  time 
unaware  of  Mikulicz's  observations  upon  chloroform  or  of  any 
other  studies  of  a  like  sort.  The  experiments  were  published  in 
the  Medical  Nlivs  of  March  2,  1895.  The  blood  was  examined 
before,  during,  and  after  etherization.  Twenty-seven  cases  were 
studied.  In  the  majority  there  was  a  distinct  fall  of  haemo- 
globin.   It  was  also  observed  that  the  red  corpuscles  were  often 

'   Dental  Cosmos,  March,  1869. 

■-'   Beilage  z.  Centralbl.  f.  Chir.,  1890,  No.  25.  '   Lancet,  September  9,  1893. 


74  DA   COSTA    AND     KALTEYER, 

altered  in  shape,  but  that  they  were  not  diminished  in  number. 
The  diminution  in  the  amount  of  haemoglobin  was  found  to  be 
most  marked  in  anaemic  individuals — an  observation  which 
seems  to  afford  an  explanation  of  the  reason  why  operative 
shock  is  usually  so  profound  and  prolonged  in  the  anaemic.  In 
Da  Costa's  cases  the  counts  were  made  by  means  of  a  Thoma- 
Zeiss  haemocytometer,  and  the  haemoglobin  was  estimated  by 
the  instruments  of  Gowers  and  Fleischl.  That  the  fall  in  haemo- 
globin was  not  entirely  due  to  hemorrhage  was  indicated  by 
the  fact  that  it  occurred  in  some  bloodless  cases  ;  for  instance, 
an  examination  of  a  strictured  rectum,  the  reduction  by  taxis  of 
an  inguinal  hernia,  and  the  breaking  up  of  adhesions  in  an 
ankylosed  metacarpo-phalangeal  joint.  It  was  also  noted  that 
ether  given  as  an  anaesthetic  markedly  lowers  the  temperature. 
This  fall  of  temperature  begins  with  the  anodyne  stage,  and 
averages  from  i°  to  3°  F.,  but  may  reach  4°  or  even  5°  F. 
That  the  fall  is  not  due  purely  to  shock  is  proved  by  its  occur- 
rence in  trivial  operations  and  by  the  rapid  ascent  of  the  tem- 
perature on  suspending  the  administration  of  the  anaesthetic. 

Among  the  conclusions  deduced  from  these  experiments  were 
the  following : 

"Etherization  produces  a  marked  diminution  in  the  hitmo- 
globin  of  the  blood. 

"The  red  corpuscles  and  the  h^tmoglobin  are  especially 
affected  in  blood  previously  diseased. 

"  Irregular  records  are  due  to  faulty  observation,  to  the 
presence  of  altered  hemoglobin  in  the  blood,  to  the  faulty 
aberration  as  to  the  color  of  a  Fleischl  instrument,  or  to  taking 
blood  before  anaesthesia  is  complete. 

"  The  white  corpuscles  show  irregular  changes  which  are  not 
characteristic,  and  exhibit  variations  not  more  pronounced 
than  would  be  found  in  the  same  number  of  samples  of  normal 
blood  on  different  examinations. 

"Age  does  not  apparently  influence  the  results. 

"The  often  quoted  observation  as  to  the  effect  upon  the 
haemoglobin  of  shock  and  hemorrhage  requires  enlarged  repeti- 
tion upon  human  beings  before  the  statements  that  hemorrhage 


BLOOD     CHANGES     INDUCED     BY     ETHER.  75 

causes  a  great  fall  in  the  amount  of  haemoglobin,  but  that  shock 
does  not  affect  it,  can.be  accepted. 

"  Prolonged  anaesthesia  profoundly  deteriorates  the  blood 
and  strongly  militates  against  recovery ;  hence,  rapidity  of 
operation  is  most  desirable." 

One  or  two  other  conclusions  which  do  not  seem  to  bear  upon 
our  present  study  are  not  cited. 

The  above  quoted  studies,  if  correct,  indicate  that  the  blood 
of  a  patient  should  be  examined  before  an  anaesthetic  is  ad- 
ministered, and  that  if  marked  anaemia  exists,  or  if  the  amount 
of  hitmoglobin  is  lowered,  the  administration  of  an  ant-esthetic 
must  be  regarded  with  apprehension.  If  it  is  found  necessary 
to  employ  one.  it  must  be  administered  by  a  skilled  anresthetist. 
As  little  as  possible  should  be  given  ;  oxygen  should  be  admin- 
istered with  it;  the  surgeon  should  work' rapidly ;  the  patient 
should  be  carefully  protected  from  cold,  and  vigorous  efforts  to 
bring  about  reaction  should  be  promptly  made  as  soon  as  the 
operation  is  complete,  or  even  during  its  performance.  If  the 
amount  of  haemoglobin  is  very  low,  no  general  anaesthetic 
should  be  given. 

Da  Costa  made  no  attempt  to  obtain  information  as  to  the 
lowest  amount  of  haemoglobin  which  is  consistent  with  the 
fairly  safe  administration  of  an  anaesthetic.  Mikulicz  estimates 
it  at  30  per  cent,  for  chloroform.  He  believes  that  the  admin- 
istration of  chloroform  when  the  haemoglobin  is  only  20  per 
cent,  will  be  followed  by  respiratory  paralysis.  In  three 
patients  who  died  of  operative  collapse,  Mikulicz  found  but  15 
per  cent,  of  haemoglobin  remaining  in  the  blood. 

These  views  in  regard  to  the  deteriorative  influence  of  ether 
upon  the  blood  have  been  accepted  by  some  and  rejected  by 
others.  It  has  generally  been  accepted  that  ether  causes  leu- 
cocytosis  which  is  probably  of  a  toxic  character,  but  its  action 
upon  the  red  corpuscles  and  haemoglobin  is  still  a  matter  of 
dispute.  Von  Lerber'  reports  a  study  of  the  blood  in  lOi 
cases  after  the  inhalation  of  ether.      He  asserts  that  in  most  in- 

1  Centr,)lbl.  f.  Gyniikologie.  1897,  No.  19. 


76  DA  COSTA     AND     KALTEYER, 

stances  the  haemoglobin  was  unaltered.  He  found  leucocytosis, 
but  the  red  corpuscles  were  very  little  changed,  either  in  num- 
ber or  in  appearance.  He  made  a  spectroscopic  study  of  the 
urine,  but  as  he  was  unable  to  find  urobilin,  he  concluded  that 
ether  does  not  exert  any  harmful  influence  upon  the  blood  and 
does  not  set  free  ha.'moglobin.  The  belief  that  because  urobi- 
lin is  not  discovered  in  the  urine  none  is  set  free  in  the  blood 
is,  to  our  mind,  not  warranted  by  conclusive  observations. 
Von  Lerber,  however,  points  out  that  the  more  prolonged  the 
anaesthesia  the  more  marked  is  the  leucocytosis. 

Oliver'  says  that  observations  should  be  made  upon  animals 
in  order  to  determine  whether  normal  red  corpuscles  are  affected 
by  ether.  He  believes  that  observations  made  before,  during, 
and  after  operations  are  entirely  unreliable,  because  the  opera- 
tion, whether  or  not  it  is  accompanied  by  bleeding,  disturbs  the 
composition  of  the  blood.  Oliver  made  a  number  of  observa- 
tions upon  rabbits,  keeping  each  animal  under  the  influence  of 
the  aniiisthetic  one  hour.  He  found  the  average  blood  decimal 
to  be  I.I  before  anaesthesia,  and  0.98  after  anaesthesia  ;  during 
anaesthesia  the  corpuscles  appeared  to  be  normal,  and  there 
were  apparently  no  injurious  after-effects.  He  says  that  this 
indicates  that  ether  does  not  affect  normal  red  corpuscles,  but 
he  admits  that  it  may  affect  those  that  are  diseased,  and  he  is 
quite  sure  that  the  resisting  power  of  the  stroma  of  the  cor- 
puscles must  vary  under  the  influence  of  ether. 

Dudley  W.  Buxton"  says  :  "  In  every  case,  blood  removed 
from  the  body  and  shaken  with  an  anaesthetic  shows  destruction 
of  the  corpuscles  and  reduction  with  pouring  out  of  haemo- 
globin ;  and  it  would  also  appear  that  a  similar  if  less  marked 
phenomenon  occurs  in  the  body."  Because  of  some  observa- 
tions he  has  made,  Buxton  has  become  persuaded  that  there  is 
a  decided  diminution  in  hremoglobin  when  an  animal  is  under 
the  influence  of  ether,  chloroform,  or  nitrous  oxide.  He  says: 
"  It  is,  however,  not  improbable  that  factors  other  than  the  an- 
jiesthetics  may  be  found  at  work   in   bringing  about  this  result. 

'  Lancet,  June  27,  1896.  '^  Ibid.,  February  i.  1896. 


BLOOD    CHANGES     INDUCED    BY     ETHER.  y/ 

The  combination  or  association  between  the  gaseous  anaes- 
thetics, or  vapors,  and  the  constituents  of  the  blood  must  be  a 
U^ose  one,  since  in  their  presence  oxygen  is  displaced.  Were 
they  to  form  combinations  as  stable  as  that  which  carbonic 
oxide  establishes,  not  only  would  the  an;Lsthetic  displace  the 
oxygen,  but  it  would  render  impossible  the  re-formation  of 
oxyhasmoglobin  ;  hence,  death  must  result."  Buxton  goes  on 
to  state  that  it  is  impossible  to  say  whether  the  corpuscles,  in 
some  cases  after  the  administration  of  an  anaesthetic,  have  a 
lessened  power  of  taking  up  oxygen,  but  that  it  seems  probable 
that  such  is  the  case. 

Hamilton  Fish^  has  contributed  an  extremely  valuable  article, 
which  he  designates  "The  Importance  of  Blood  Examinations 
in  Reference  to  General  Anaesthetization  and  Operative  Pro- 
cedures." He  takes  the  affirmative  on  the' question  of  whether 
or  not  ether  reduces  haemoglobin  and  affects  red  corpuscles. 
He  believes  that  ana:;sthetics  may  lessen  tissue  resistance,  and 
thus  lead  to  septic  lesions;  and  he  thinks  that  the  condition  of 
the  blood  is  a  fairly  accurate  gauge  of  the  patient's  general  con- 
dition, and  that  the  blood  should  always  be  examined  before 
the  administration  of  an  anaesthetic.  He  says  that  those  who 
labor  under  neurasthenia,  anaemia,  chlorosis,  leukemia,  and 
the  lymphatic  temperament  have  blood  in  which  marked 
changes  can  be  demonstrated  ;  and  that  all  of  these  patients 
stand  operation  and  also  anaesthesia  badly.  Fish  advocates 
the  belief  that  an  anaesthetic  extracts  oxygen  from  oxyhaemo- 
globin,  and  combines  with  the  latter;  and  he  further  asserts 
that  in  patients  with  less  than  50  per  cent,  of  hiumoglobin 
oxygen  is  taken  away  from  corpuscles  which  are  so  poor  in 
that  element  that  they  cannot  spare  it.  As  a  consequence, 
such  corpuscles  are  unable  to  give  up  any  oxygen  to  the  tissues, 
and  these  patients,  when  under  the  influence  of  ether,  will  show 
evidence  of  collapse.  Fish  reminds  us  that  respiration  depends 
upon  the  nervous  system  and  upon  the  amount  of  h^iimoglobin 
in  the  blood,  and  that  if  h.tmoglobin  is  reduced  below  a  certain 

'   Annals  of  Surgery,  July,  1899. 


jS  DA   COSTA     AND     KALTEYEK, 

limit  respiration  will  cease.  He  thinks  that  the  minimum  is 
20  per  cent.,  and  refers  to  the  observations  of  Mikulicz,  that  in 
three  cases  dying  of  collapse  during  operation,  15  per  cent,  of 
hitnioglobin  was  found  remaining  in  the  blood.  In  Fish's 
opinion,  the  safest  rule  is  not  to  give  an  anaesthetic  if  the 
hfemoglobin  is  under  50  per  cent. ;  anything  above  80  per  cent, 
he  considers  normal.  An  amount  of  anesthetic  which  is  per- 
fectly harmless  when  there  is  80  per  cent,  of  haemoglobin  may 
be  extremely  dangerous  when  there  is  but  50  per  cent.  Fish 
also  points  out  the  important  fact  that  safe  anctsthesia  depends 
not  alone  upon  a  good  percentage  of  haemoglobin,  but  also 
upon  the  existence  of  a  normal  or  increased  number  of  poly- 
nuclear  neutrophils.  He  regards  the  leucocytosis  of  anaes- 
thesia as  phagocytic  in  character,  and  as  a  measure  of  individual 
resistance.  He  believes  that  the  blood  should  be  examined  not 
only  before  but  during  anaf;sthesia,  because  the  first  evidence  of 
approaching  danger  may  be  found  in  a  blood  change.  He  also 
points  out  the  interesting  fact  that  at  an  altitude  of  one  mile 
normal  haemoglobin  is  reduced  from  12  to  15  percent  during 
the  first  hour  of  anaesthesia. 

Dr.  Joseph  C.  Bloodgood,'  of  the  Johns  Hopkins  Hospital, 
in  reviewing  Dr.  Hamilton  Fish's  article,  entirely  agrees  with 
that  author's  conclusions,  and  cites  several  cases  occurring  in 
the  Johns  Hopkins  Hospital  to  confirm  these  views. 

From  the  above  quoted  opinions  it  will  be  observed  that 
wide  divergences  exist  among  the  views  of  the  different  writers 
upon  this  subject — between  the  views  which  J.  Chalmers 
Da  Costa  put  forth  in  1895  and  the  results  of  the  experiments 
upon  rabbits  made  by  Oliver  ;  between  the  broad  affirmation  of 
the  belief  that  ether  lowers  haemoglobin  and  has  a  destructive 
influence  upon  corpuscles,  in  the  article  by  Hamilton  Fish,  the 
absolute  denial  of  this  by  Von  Lerber,  and  the  rather  conservative 
opinion  of  Dudley  Buxton.  The  controversialists  are  as  the  two 
knights  of  allegory  who  stood  upon  opposite  sides  of  the  shield 
disputing  as  to  the  words  graven  upon  it.  Each  saw  his  own 
side,   and    each   was   right   and   each  was   wrong.     It  becomes 

'    Progressive  Medicine,  1900,  vol.  iv. 


BLOOD     CHANGES     INDUCED     BV     ETHEK.  79 

evident  that  some  of  the  observations  must  be  entirely  errone- 
ous, or  else  undiscovered  factors  and  unrecognized  elements  ex- 
ist in  the  problem  which  make  all  previous  observations  never 
entirely  correct  and  never  completely  wrong.  These  discrep- 
ancies and  disagreements  may  depend  upon  the  personal  incre- 
ment, upon  the  employment  of  different  methods  to  estimate 
the  h;\.'moglobin,  upon  the  different  altitudes  above  the  sea  at 
which  the  experiments  were  made;  upon  the  daily  and  nightly 
oscillations  which  are  known  to  occur  in  the  percentage  of 
haemoglobin  and  corpuscles  ;  upon  the  uncertain  results  obtained 
by  the  h.tmoglobinometer ;  upon  the  different  methods  taken 
to  secure  the  blood,  and  the  fact  that  it  may  have  been  taken 
from  different  portions  of  the  body;  upon  the  fact  that  the  ex- 
tremity from  which  the  blood  was  taken  may  or  may  not  have 
been  elevated,  and  also  that  massage  and  manipulation  may  or 
may  not  have  been  employed;  because  in  some  cases  digestion 
may  have  been  going  on,  and  in  others  it  may  not  have  been  ; 
and  particularly  upon  the  fact  that  in  some  cases  the  blood 
may  have  been  concentrated  by  purgation  and  diaphoresis,  and 
in  others  it  may  not  have  been  so  concentrated. 

In  Da  Costa's  former  cases  the  patients  in  many  instances 
were  taken  from  the  dispensary  and  etherized  without  pre- 
vious preparation.  In  this  new  series  of  cases  we  determined 
that  the  patients  should  be  carefully  prepared  for  operation — a 
preparation  which  involves  concentration  of  the  blood  by  pur- 
gation, which  concentration  is  usually  added  to  by  profuse  per- 
spiration during  the  anaesthetic  state.  We  further  determined  to 
have  all  the  blood  examinations  made  by  a  thoroughly  com- 
petent third  party,  who  was  to  make  them  all  in  exactly  the 
same  manner,  and  was  to  have  no  preconceived  views,  and  who, 
in  consequence,  would  not  be  lured  from  the  path  of  accurate 
observation  by  any  theoretical  jack-o'-lantern.  We  selected  for 
this  work  Dr.  A.  G.  Ellis,  the  Pathological  Resident  of  the 
Jefferson  College  Hospital,  who  performed  it  with  the  utmost 
skill  and  care  ;  and  we  wish  here  to  extend  to  him  our  thanks. 
Further,  we  decided  that  the  table  when  completed  should  be 
broken  up  into  numerous  subtables,  according  to  the  time  before 


80  DA   COSTA     AND     KALTEYER, 

and  after  operation  the  blood  was  examined,  to  the  duration  of 
the  anaesthesia,  to  the  amount  of  ether  used,  to  the  estimated 
quantity  of  blood  lost,  etc. 

It  is  our  aim  in  these  investigations  to  consider  the  subject 
as  far  as  possible  from  a  practical  stand-point  rather  than  from 
an  experimental  view-point.  We  concluded  to  gather  fifty  cases, 
taken  out  of  the  general  run  of  patients  in  a  busy  hospital — the 
Jefferson  Medical  College  Hospital.  The  cases  were  selected 
from  the  various  wards,  surgical,  gynecological,  etc.  The  blood 
examinations,  which  were  made  before  and  after  the  operations, 
consisted  of  the  estimation  of  the  number  of  erythrocytes,  the 
haemoglobin  percentage,  the  color  index,  and  the  number  of 
leucocytes.  Differential  counts  of  the  leucocytes  were  not 
undertaken,  for  it  was  not  our  object  to  study  the  leucocytic 
changes  in  detail.  The  results  of  the  blood  examination  before 
the  operation  were  compared  with  those  after  the  operation.  It 
was  practically  impossible  to  always  set  a  definite  time  before 
the  operation  as  the  period  in  which  the  observation  should  be 
made,  so  we  decided  to  make  the  examination  in  a  number  of 
cases  within  a  reasonable  period  preceding  the  operation — that 
is,  within  some  hours  of  the  time  of  going  to  the  operating- 
room.  In  other  instances  the  blood  examinations  were  made 
some  time  before  going  to  the  clinic-room,  on  account  of  post- 
ponement of  the  operation.  In  some  cases  examination  was 
deliberately  made  a  considerable  time  before  operation  in  order 
to  anticipate  preparatory  methods  of  treatment.  Similar  diffi- 
culties were  encountered  in  arriving  at  the  proper  time  for  the 
blood  examinations  after  the  operation.  The  counts  following 
the  operation  were  made  either  immediately  after  or  upon  the 
day  following.  Examinations  were  not  made  during  the  anaes- 
thetic state,  for  our  particular  aim  was  to  determine  the  changes 
which  follow  etherization  rather  than  the  changes  that  are  noted 
during  the  anaesthetic  period. 

Blood  Concentration. 

The    problem    of    blood   concentration    naturally   presented 
itself,   because    the    preparatory    treatment    includes    measures 


BLOOD     CHANGES     INDUCED     BY     ETHER.  01 

which  tend  to  increase  the  elimination  of  the  watery  principles 
of  the  body,  while  the  intake  of  fluids  is  always  reduced  prior 
to  and  for  a  time  after  the  operation. 

The  general  rules  gov Qvn'xrvg  preparatory  measures  of  treatment 
at  the  Jefferson  Medical  College  Hospital  consist  of 

{a)  A  hot  bath. 

(d)  Active  purgation. 

(c)  Reduction  of  diet  and  withholding  of  all  food  and  liquid 
for  some  hours  preceding  the  operation. 

(d)  Occasionally,  though  rarely,  the  administration  of  heart 
stimulants. 

Cause  of  Blood  Concentration. 

It  is  generally  admitted  that  such  conditions  as  increased 
blood-pressure,  diarrhcea,  profuse  sweating,' constant  vomiting, 
the  v/ithdrawal  of  a  large  quantity  of  serous  fluid,  which  is 
rapidly  replaced  by  the  transfusible  elements  of  the  blood,  and 
deprivation  of  fluids — all  tend  to  produce  blood  inspissation. 
It  is  a  well-known  fact  that  the  blood  of  individuals  suffering 
from  Asiatic  cholera  shows  concentration  to  a  high  degree. 
The  finding  of  6,000,000  or  more  red  blood-cells  per  cubic  milli- 
metre in  this  disease  is  not  unusual.  Cabot/  in  referring  to  the 
work  of  Hay  On  the  Action  of  Saline  Cathartics^  states  that 
"  Hay  gives  the  following  figures  showing  the  effect  of  sulphate 
of  sodium  in  concentrating  the  blood  :  Subject,  a  healthy  man, 
aged  thirty-three  years  ;  3.35  p.m.,  red  corpuscles,  5,250,000;  was 
given  85  c.c.  of  a  concentrated  solution  of  sulphate  of  sodium  in 
water.  Thirty-five  minutes  later  the  blood-count  showed  red 
corpuscles,  6,540,000;  sixty-five  minutes  later  the  blood-count 
showed  red  corpuscles,  6,790,090  ;  four  hours  later  the  blood- 
count  showed  red  corpuscles,  4,930,000.  Evidently  much  fluid 
was  drawn  out  of  the  bloodvessels,  and  then  within  four  hours 
the  tissues  had  supplied  the  loss,  and  the  blood  had  returned 
to  its  normal  density.  Hay  also  showed  that  a  dilute  solution 
of  the  same  drug  had  far  less  effect  in  concentrating  the  blood. 

1  Clinical  Examination  of  the  Blood. 
Am  Surg  6 


82  DA   COSTA    AND     KALTEYER, 

Further,  he  demonstrated  that  if  blood  is  already  concentrated 
when  the  saline  is  given  no  purgative  effect  follows." 

Concentration  is  well  shown  after  profuse  sweating.  Oliver^ 
reports  temporary  apoplasia  produced  by  a  Turkish  bath.  In 
this  case  the  corpuscular  percentage  was  91  before  the  bath, 
while  immediately  after  the  bath  it  was  106,  and  two  hours  after 
the  bath  the  percentage  fell  to  almost  99.  Thirty  ounces  of 
beer  were  ingested  half  an  hour  after  the  bath. 

Oliver,'  in  referring  to  the  variations  in  the  volume  of  the 
plasma,  states  that :  "  When,  for  example,  the  output  of  water, 
whether  by  the  kidneys,  the  skin,  or  the  bowels,  temporarily 
exceeds  the  income,  the  volume  of  the  plasma  is  for  a  time  re- 
duced, and  there  is  a  proportionate  rise  in  the  corpuscles."  He 
further  states  that  "  the  concurre?it  variations  in  the  percentage 
of  the  corpuscles  and  haemoglobin,  which  have  been  so  repeat- 
edly pointed  out,  are  indeed  volumetric  indications  of  the  circu- 
lation of  the  water  into  or  from  the  blood — into  it  from  the 
digestive  tract  and  the  tissues,  and  from  it  by  the  kidneys, 
skin,  and  lungs,  and  probably  into  the  muscles  during  exercise. 
The  blood  is  continually  tending  to  balance  its  income  and  out- 
put of  water,  and  is  thus  always  striving  for  a  mean  ;  but  not- 
withstanding this  wonderful  persistent  adjustment,  variations  in 
the  proportion  of  water  present  in  the  plasma  are  at  the  same 
time  shown  by  these  observations  to  be  constantly  taking  place 
within  certain  physiological  limits." 

Blood  inspissation  is  also  produced  by  increased  blood-pres- 
sure. For  example,  small  doses  of  suprarenal  extract  increase 
arterial  tension,  and  hence  favor  elimination  of  water  and  induce 
polycythremia.  It  is  worthy  of  mention  that  in  the  blood  con- 
centration occurring  in  the  healthy  individual  within  physiologi- 
cal limits  the  rise  in  the  corpuscular  and  h^vmoglobin  percentage 
is  parallel.  The  blood  decimal,  therefore,  does  not  change.  The 
rapidity  with  which  the  blood  loses  some  of  its  diffusible  ele- 
ments, therefore,  must  always  be  borne  in  mind,  and  the  quick- 
ness with  which  the  blood  is  again  diluted  is  a  matter  no  less 

I  Lancet,  June  27,  1896.  '^  Ibid. 


BLOOD    CHANGES     INDUCED     BY     ETHER.  83 

important.  It  is  undoubtedly  true  that  the  loss  of  the  watery- 
elements  of  the  plasma  is  only  transitory,  nevertheless  the 
rapidity  with  which  the  blood  tends  to  reach  the  normal  proba- 
bly varies  greatly  in  individual  cases,  and  is  modified  by  many 
factors.  The  following  statement  of  Cabot'  in  regard  to  the 
subject  of  blood  concentration  is  indeed  worthy  of  careful  con- 
sideration at  all  times  when  dealing  with  blood  examinations. 
"  In  the  presence,  therefore,  of  any  such  reason  for  the  con- 
centration of  the  blood,  we  should  always  modify  our  ordinary 
methods  of  inference  from  the  blood-counts." 

Blood  Destruction  [Hcemolysis)  and  Blood  Formation  [HcBmo- 

genesis). 

In  health  the  number  of  erythrocytes  and  the  amount  of 
haemoglobin  maintain  a  uniform  standard — ;the  formation  of  the 
new  red  blood-cells  and  the  destruction  of  the  colored  elements 
progress  uniformly.  The  subject  regarding  the  average  life 
of  the  erythrocytes  has  received  much  discussion,  but  still 
remains  an  unsettled  question.  It  has  been  suggested  that  the 
average  duration  of  life  of  the  chromocyte  appears  to  be  about 
two  weeks  or  less.  Therefore,  357,152  red  blood-cells  per  cubic 
millimetre  are  destroyed  each  day — in  other  words,  the  destruc- 
tion is  at  the  rate  of  248—  per  minute  in  each  cubic  millimetre 
of  blood.     Haemogenesis  progresses  accordingly. 

Blood  Regeneration. 

It  is  essential,  in  order  to  base  our  conclusions  upon  scientific 
principles,  to  consider  the  generally  accepted  views  governing 
blood  regeneration.  These  may  be  summarized  as  follows  : 
Immediately  following  a  loss  of  blood,  for  example,  a  trau- 
matic hemorrhage,  the  erythrocytes  and  the  haemoglobin  are 
reduced  proportionately ;  in  a  short  time  the  other  tissues  of  the 
body  compensate  for  the  volume  of  fluid  lost  from  the  blood. 
Following  this  dilution,  erythrocytic  regeneration  progresses 
rapidly,  and  the  number  of  corpuscles   lost  is   restored  to  the 

1  Clinical  E.xamination  of  the  Blood, 


84  DA  COSTA     AND    KALTEYER, 

proper  level  in  a  short  time;  the  haemoglobin,  however,  is  not 
replaced  so  quickly.  Therefore,  the  newly  formed  corpuscles 
in  the  circulation  are  deficient  in  coloring-matter,  and  the  total 
haemoglobin  percentage  is  below  the  corpuscular  percentage, 
consequently  there  is  a  reduction  in  the  average  blood  decimal. 
After  the  lapse  of  some  time  the  haemoglobin  is  restored  and 
the  erythrocytic  regenerative  properties  of  the  blood-making 
organs  gradually  become  normal. 

Blood  Concentration  and  Ancemia. 

Blood  concentration  may  progress  or  be  associated  with 
anaemic  states.  In  cases  of  this  kind  the  total  volume  of  blood 
is  reduced,  the  number  of  erythrocytes  may  appear  to  be  nor- 
mal or  exceed  the  normal,  while  the  haemoglobin  will  not  pre- 
sent the  same  increase,  although  the  percentage  may  be  increased, 
but  the  total  amount  is  diminished,  as  is  shown  by  the  lowered 
color  index.  When  the  blood  becomes  diluted  and  inspissation 
disappears  the  percentage  of  corpuscles  and  haemoglobin  is 
lowered,  while  the  blood  decimal  remains  unaltered  unless  im- 
provement follows,  which  will  be  indicated  by  a  rise  in  the 
corpuscular  haemoglobin  value. 

Records. 

In  gathering  our  clinical  data  we  particularly  emphasize  the 
points  bearing  upon  the  conditions  which  produce  blood  inspis- 
sation, endeavoring  to  determine,  therefore,  in  a  general  way, 
the  loss  of  the  watery  constituents  of  the  body.  The  task  of 
gathering  the  clinical  notes  was  assigned  to  the  resident  physi- 
cians of  the  Jefferson  College  Hospital.  The  following  chart 
was  prepared  so  as  to  facilitate  their  work  : 

Number.  Name.  Age.  Sex.  Date. 

Nativity.  Occupation.  Ward.  Physician. 

Diagnosis.  Date  of  admission. 

Date  of  discharge. 

Revised  diagnosis.  Result. 

History. 

Physical  examination. 

Character  and  amount  of  urine  in  twenty-four  hours  before  and  after  anaesthesia. 


BLOOD    CHANGES     INDUCED     BY    ETHER.  85 

Character  and  amount  of  vomit  before  and  after  anaesthesia. 

Character  and  amount  of  bowel  movement  before  and  after  ansesthesia. 

Amount  of  sweating  before  and  after  anaesthesia. 

Remarks.     (Was  any  large  quantity  of  fluid  lost  before  or  after  operation?) 

Date.  Hour,  and  character  of  operation. 

Blood  loss. 

Duration  of  anaesthesia. 

Character  and  amount  of  anassthetic. 

Blood  Examinations. 

Date  and  hour  before  operation.  Date  and  hour  after  operation. 

Haemoglobin.  Haemoglobin. 

Erythrocytes.  Erythrocytes. 

Leucocytes,  Leucocytes. 

Color  index.  Color  inde.v. 

HcBmatological  Methods. 

In  procuring  the  blood  for  examination  the  following  rules 
were  always  observed.  The  patients  were  in  the  recumbent 
posture;  the  blood  was  taken  from  the  tip  of  the  finger.  In  no 
case  was  the  hand  oedematous.  The  skin  was  cleansed  with 
water  or  a  little  soap  and  water ;  next  with  alcohol,  and  was 
then  dried.  The  part  was  warmed  by  a  gentle  friction.  Care 
was  taken  not  to  excite  active  hyperaemia  by  vigorous  rubbing. 
The  puncture  was  effected  with  a  clean  needle  having  a  cutting 
surface,  and  was  made  deep  enough  to  insure  a  free  flow  of  blood 
without  squeezing  the  part  near  the  wound.  The  first  drop  was 
always  wiped  away.  The  number  of  erythrocytes  and  leuco- 
cytes was  estimated  with  the  Thoma-Zeiss  hcEmocytometer. 
In  determining  the  number  of  the  red  cells  a  2  per  cent,  salt 
solution  was  used  as  a  diluent  in  the  proportion  of  one  part  of 
blood  to  20C>  parts  of  the  solution.  A  i  per  cent,  acetic  acid 
solution  was  used  as  the  diluting  fluid  in  the  proportion  of  i  to 
20  in  estimating  the  number  of  leucocytes.  In  ascertaining  the 
number  of  erythrocytes  the  corpuscles  in  80  squares  were 
counted,  while  the  corpuscles  in  400  squares  were  enumerated 
in  determining  the  number  of   leucocytes.     The  haemoglobin 


86 


DA  COSTA     AND     KALTEYER, 


estimations  were  made  with  Oliver's  haemoglobinometer,  except 
in  4  cases,  in  which  the  Fleischl  instrument  was  employed. 


Table  I. 


Before  ansesthesia. 

After  anaesthesia. 

DiflFerence. 

Color 

Hsemo. 

Haemo. 
Color  loss.        loss. 

index 

No. 

Corpus- 

Color 

Hsemo. 

Corpus- 

Color 

loss. 
Color 
index 
gain. 

cles. 

index. 

perct. 

cles. 

index. 

per  ct. 

60 

Color  gain. 

Hsemo. 
gain. 

1 

3,245,000 

0.89 

58 

3,920,000 

0.76 

675,000-1- 

2+ 

0.13 

2 

4.170,000 

0.9 

75 

5,390,000 

0.742 

80 

1,220,000+ 

5+ 

0.158 

3 

3,795,000 

0.724 

55 

4,330.000 

0.577 

50 

535,000-1- 

5— 

0.147 

4 

4,050,000 

0.92 

75 

5,160.000 

0.82 

85 

1,110,0004- 

10+ 

0.10 

5 

5,340,000 

0.889 

95 

5,370,000 

0.884 

95 

30,000-1- 

0+  0— 

0.005 

6 

5,130,000 

0.926 

95 

5,250,000 

0.9 

95 

120,000  + 

0+  0— 

0.026 

7 

4,575,000 

0.82 

75 

4,600,000 

0.76 

70 

25,000  + 

5— 

0.06 

8 

4,680,000 

0.908 

85 

4,850,000 

0.  H24 

80 

170,000  + 

5 — 

0.084 

9 

4,750,000 

0.863 

82 

4,620,000 

0.811 

75 

130.000— 

7 — 

0.052 

10 

4,520,000 

0.94 

85 

4,950,000 

0.808 

80 

430.000  + 

5- 

0.132 

11 

4,500,000 

0.944 

85 

4,240,000 

0.943 

80 

260;000- 

5— 

0.001 

12 

4,375,000 

0.857 

75 

4,387,000 

0.683 

60 

12,500+ 

15— 

0.174 

13 

3,820,000 

0.982 

75 

4,810,000 

0.779 

75 

990,000+ 

0+  0— 

0.203 

14 

5,660.000 

0.75 

85 

5,490,000 

0.728 

80 

170,000- 

5— 

0. 022 

15 

5,210,000 

0.959 

100 

5,360,000 

0.886 

92 

150.000+ 

5— 

0.073 

16 

3,680,000 

0.87 

64 

5,230,000 

0.592 

62 

1,550,000+ 

2— 

0.278 

17 

4,160,000 

0.S41 

70 

3,900,000 

0.77 

60 

260,000— 

10- 

0.071 

18 

4,940,000 

0. 88 

87 

5,600,000 

0.848 

9§ 

660,000+ 

8  + 

0.032 

19 

5,140,000 

0.  826 

85 

4,850,000 

0.824 

80 

290,000— 

.5— 

0.002 

20 

4,710,000 

0.934 

88 

5,925.000 

0.798 

95 

1,215,000  + 

7  + 

0.136 

21 

5,560,000 

0.809 

90 

5,800,000 

0.801 

93 

240,000+ 

3+ 

0.008 

22 

5,190,000 

0.915 

95 

5,880,000 

0.85 

100 

690,000+ 

5+ 

0.065 

23 

4,920,000 

0.945 

93 

5,740,000 

0.827 

95 

820.000+ 

2+ 

0.118 

24 

3,970.000 

1.000 

80 

3,890,000 

0.964 

75 

80.000— 

5- 

0.036 

25 

4,440,000 

0.822 

73 

5,650,000 

0.796 

90 

1,210.000+ 

17  + 

0.026 

26 

4,780,000 

0.868 

83 

4,870,000 

0.739 

72 

90.000+ 

11— 

0.129 

27 

4,820,000 

0.964 

83 

5,137,000 

0.924 

95 

317,000  + 

12— 

0.040 

28 

5,430,000 

0.874 

95 

6,130,000 

0.792 

loo 

700,000+ 

5+ 

0.082 

29 

5,650,000 

0.911 

103 

6,070,000 

0.807 

98 

420,000  + 

5— 

0.104 

30 

5,070,000 

0.936 

95 

6,375,000 

0.902 

115 

1,305,000+ 

20+ 

0.034 

31 

4,880,000 

0.  922 

90 

5,360,000 

0.904 

97 

480,000+ 

7  + 

0.018 

32 

5,480,000 

0.865 

95 

6,620,000 

0.83 

110 

1,140,000+ 

15+ 

0.035 

33 

5.520,000 

0.995 

110 

6,120,000 

0.776 

95 

600,000+ 

15— 

0.219 

34 

5,160,000 

0.92 

95 

6,090,000 

0.862 

105 

930.000  + 

10  + 

0.058 

35 

5,040,000 

0.992 

100 

5,720,000 

0.83 

95 

680,000  + 

5— 

0.162 

36 

5,590,000 

0.983 

110 

6,225,000 

0.963 

120 

635,000  + 

10+ 

0.020 

37 

5,890,000 

0. 933 

110 

6.710,000 

0.842 

113 

820.000+ 

3  + 

0.091 

38 

6,130,000 

0.938 

115 

5,380,000 

0.93 

100 

750,000— 

15— 

0.008 

39 

3,900,000 

0.641 

50 

4,060,000 

0.492 

40 

160,000+ 

10- 

0.149 

40 

6,280,000 

0.954 

120 

6,070,000 

0.98 

113 

210,000- 

7 

0.024 

41 

6,100,000 

0.983 

120 

6,170,000 

0.  988 

122 

70,000* 

2+ 

0.    + 

42 

4,920,000 

0.873 

80 

5,300,000 

0.66 

70 

380,000+ 

10- 

0.213 

43 

5,550,000 

1.030 

115 

6,030,000 

0.829 

100 

480,000  + 

15— 

0.201 

44 

4,600,000 

1.000 

92 

5,050.000 

0.891 

90 

450,000+ 

2— 

0.109 

45 

5,350,000 

0.981 

105 

4,880,000 

0.922 

90 

470,000- 

15— 

0.059 

46 

4,880,000 

1.020 

100 

6.040,000 

0.91 

110 

1,160,000+ 

10  + 

0.11 

47 

5,330,000 

0.863 

92 

5,750,000 

0.782 

90 

420,000+ 

2— 

0.081 

48 

4,700,0fi0 

0.957 

90 

5.120,000 

0.859 

88 

420,000  + 

2— 

0.098 

49 

5,500,000 

0.936 

103 

5,700,000 

0.831 

95 

200,000  + 

8— 

0.105 

50 

5,940,000 

0.942 

112 

89 

6,080,000 

0.904 

110 
86-1- 

1,140,000  + 
149,360+ 

2— 

■ 

0.038 

Aver. 

4,977,440 

0.9C3 

5,126,800 

0.821 

»- 

0.082 

BLOOD    CHANGES     INDUCED     BY    ETHER.  8/ 

Tabulation  of  Cases. 

After  the  various  facts  had  been  collected  the  50  cases  were 
arranged  in  tabular  form.  The  facts  included  in  this  table  are 
the  name,  sex,  nativity,  and  occupation  of  the  patient,  the  ward, 
diagnosis,  the  date  of  admission,  the  date  of  discharge,  the  result, 
the  character  of  the  operation,  the  date  and  hour  of  operation, 
the  estimated  blood  loss,  the  anaesthetic  employed,  the  amount 
of  the  anaesthetic  used,  the  duration  of  the  period  of  anresthesia, 
the  date  and  hour  of  the  blood  examination  before  the  opera- 
tion. The  examination  includes  the  haemoglobin  percentage, 
the  number  of  erythrocytes  per  cubic  millimetre,  the  number  of 
leucocytes  per  cubic  millimetre,  and  the  color  index.  The  date 
and  hour  of  the  blood  examination  after  the  operation,  which 
again  includes  the  haemoglobin  percentage,  the  number  of  ery- 
throcytes per  cubic  millimetre,  the  number  of  leucocytes  per 
cubic  millimetre,  and  the  color  index. 

General  Summary  of  the  Blood  Changes. 

Erythrocytes.  The  number  of  chromocytes  was  increased  in 
41  cases  and  decreased  in  9.  The  average  count  before  the 
operation  was  4,977,440.  The  average  count  following  the 
operation  was  5,126,800,  and  the  gain  was  143,360  per  cubic 
millimetre. 

Hcsmoglobin.  The  average  haemoglobin  percentage  preced- 
ing the  anaesthetic  state  was  89.  The  average  haemoglobin  per- 
centage following  the  anaesthetic  state  was  86,  showing  a  loss  of 
3  per  cent.  The  haemoglobin  revealed  an  increase  in  19  cases 
and  a  decrease  in  28  cases,  and  there  was  no  loss  or  gain  in 
three  instances.  The  average  gain  in  the  19  cases  was  8.05  per 
cent.,  while  the  average  loss  in  the  28  cases  was  7,25  per  cent. 

Color  Index.  The  average  individual  corpuscular  haemoglobin 
value  preceding  the  operation  was  0.903 ,  while  that  following  was 
0.821,  showing  an  average  loss  of  0.082.  In  49  out  of  50  cases 
the  blood  decimal  was  reduced  after  the  operation.  In  one 
instance  only  was  the  color  index  slightly  increased  after  the 
anx'sthetic  state.    This  occurred  in  case  No.  41,  the  color  index 


DA   COSTA    AND    KALTEYER. 


preceding  the  operation  was  0.983,  and  that  following  the  opera- 
tion was  0.988.  In  this  instance  the  blood  decimal  was  practi- 
cally unchanged. 

Table  II. — Group  A. 
Blood  examinations  made  a  short  time  before  and  soon  after  anaesthesia. 


Time  between  bloocl-couut 

Time  between  operation 

X  umber. 

before  operation  and 

and  blood-count  after 

operation. 

operation. 

6 

3  hours  15  minutes. 

6  hours. 

7 

2     " 

5     ' 

8 

3     " 

5     ' 

9 

2     " 

4     ' 

45  minutes. 

10 

2     "       15  minutes. 

4     ' 

30 

13 

1  hour   30       " 

2     ' 

18 

3  hours. 

5     ' 

.30  minutes. 

29 

3     ' '       30  minutes. 

6     ' 

36 

2     " 

4     ' 

37 

1  hour   30  minutes. 

5     ' 

30  minutes. 

40 

2  hours  30       " 

6     ' 

41 

1  hour   30       " 

3     ' 

44 

2  hours  30       " 

4     ' 

45 

1  hour   45       " 

4     " 

30  minutes. 

49 

3  hours. 

4     ' 

30      " 

Average  2  hour 

s  21  minutes.                  Avera 

ge  4  hours  41  minutes. 

Group  B. 

d  examinations 

made  a  short  time  before  and 

some  time  after  ansesthe 

Time  between  blood-count 

Time  between  operation 

Number. 

before  operation  and 

and  blood-count  after 

operation. 

operation. 

11 

2  hours  45  minutes. 

17  hours  30  minutes. 

12 

1  hour. 

21     ' 

45       " 

14 

2  hours. 

22     ' 

19 

1  hour   30  minutes. 

21     ' 

45  minutes. 

22 

2  hours  15       " 

21     ' 

23 

2     "       45       " 

20     ' 

'       30  minutes. 

2.5 

5     "       30       " 

22     ' 

30       " 

26 

1  hour    .'JO       " 

24     ' 

27 

4  hours. 

21     ' 

30       '' 

28 

3     •'       30  minutes. 

17     ' 

30 

4     " 

19     ' 

32 

3     "       30  minute.s. 

19     ' 

'       30  minutes. 

33 

2     " 

21     ' 

30       " 

34 

1  hour   30  minutes. 

22     ' 

3.5 

.       3  hours  30       " 

19     ' 

38 

.       3     "       15       " 

21     ' 

42 

.       3     " 

21     ' 

43 

3     "       30  minutes. 

21     ' 

'       45  minutes. 

46 

0     "       45       " 

23     ' 

47 

.       3     "      45       " 

20     ' 

'       30  minutes. 

48 

2     " 

22     ' 

50 

2     "       15  minutes. 

22     ' 

Average  2  hours  51  minutes. 


Average  20  hours  59  minutes. 


BLOOD    CHANGES     INDUCED     BY    ETHER. 


89 


Group  C. 
Blood  examinations  made  some  time  before  and  soon  after  anaesthesia. 


Number. 


16 
21 


Time  between  blood-count 

before  operation  and 

operation. 

19  hours  00  minutes. 
23     " 
16     •' 


Time  between  operation 

and  blood-count  after 

operation. 

4  hours    5  minutes. 

1  hour. 

7  hours  45  minutes. 


Average  19  hours  38  minutes. 


Average  4  hours  16  minutes. 


Group  D. 

od  examinations  made 

some  time  before 

and 

some 

time  after  antesthes 

Time  between  blood-count 

Time  between  operation 

Number. 

before  operation  and 

and  blood-count  after 

operation. 

operation. 

1 

.     23  hours  10  minutes 

19  h 

ours    5  minutes 

2 

.     29 

23       " 

19. 

7       " 

3 

..     25 

10       " 

20 

50       " 

4 

.     69 

30       " 

18 

15 

.     72 

19 

17 

.     23 

21 

30  minutes. 

20 

.     24 

30  minutes. 

22 

30       " 

24 

.     19 

19 

30       " 

31 

.     98 

30  minutes. 

21 

39 

.     26 

20 

Average  41  hours  1  minute. 


Average  20  hours  3  minutes. 


Table  III.— Group  (a). 


First  count  made 

Second  count  made 

Corpuscle  gain  or  loss. 

Col.  index 

a  short  time 

soon  after 

, 

■ 

gain  or 

before  ansesthesia. 

anfesthesla. 

Gain. 

Loss. 

loss. 

6 

5,130,000 

5,250,000 

120,000 

0.026 

7 

4,575,000 

4,600,000 

25,000 

0,06 

8 

4,680,000 

4,850,000 

170,000 

0.084 

9 

4,750,000 

4,620,000 

130,000 

0.052 

10 

4,520,000 

4,950,000 

430,000 

0.132 

13 

3,820,000 

4,810,000 

990,000 

0.203 

18 

4,940,000 

5,600,000 

660,000 

0.032 

29 

5,650,000 

6,070,000 

420,000 

0.104 

36 

5,590,000 

6,225,000 

635,000 

0.02 

37 

5,890,000 

6,710,000 

820,000 

0.091 

40 

6.280,000 

6,070,000 

210,000 

0.024 

41 

6,100,000 

6,170,000 

70,000 

+slight 

44 

4,600,000 

5,050,000 

450,000 

0.09 

45 

5,350,000 

4,880,000 

470,000 

0.059 

49 

5,500,000 

5,700,000 

200,000 

0.105 

Aver,  gain  265,000  Aver,  loss  0.077 


90 


DA  COSTA     AND     KALTEYER, 


Group  (b). 


First  count  made 

a  short  time 
lefore  anaesthesia. 

Second  count  made 

Corpuscle 

gain  or  lo.ss. 

Col.  index 

gain  or 

loss. 

h 

avjiiic  Liiiic  aiici 

anaesthesia. 

Gain. 

Loss. 

11 

4,500,000 

4,240,000 

260,000 

0.001 

12 

4,375,000 

4,387,500 

12,500 

0.174 

14 

5,660,000 

5,490,000 

170,000 

0.022 

19 

5,140,000 

4,850,000 

290,000 

0.002 

22 

5,190,000 

5,880,000 

690,000 

0.065 

23 

4,920,000     ' 

5,740,000 

820,000 

0.118 

25 

4,440,000 

5,650,000 

1,210,000 

•  0.026 

26 

4,780,000 

4,870,000 

90,000 

0.129 

27 

4,820,000 

5,137,000 

317,000 

0.040 

28 

5,430,000 

6,130,000 

700,000 

0.082 

30 

5,070,000 

6,375,000 

1,305,000 

0.034 

32 

5,480,000 

6,620,000 

1,140,000 

0.035 

33 

5,520,000 

6,120.000 

600,000 

0.219 

34 

5,160,000 

6,090,000 

930,000 

0.058 

35 

5,040,000 

5,720,000 

680,000 

0.162 

38 

6,130,000 

5,380.000 

750,000 

0.008 

42 

4,920,000 

5,300.000 

380,000 

0.213 

43 

5,550,000 

6,030,000 

480,000 

0.211 

46 

4,880,000 

6,040,000 

1,160,000 

0.11 

47 

5,330,000 

5,750,000 

420,000 

0.081 

48 

4,700,000 

5,120,000 

420,000 

0.098 

50 

5,940,000 

6,080,000 

140,000 

0.038 

Average  gain  460,204 

Average  loss  0.084 

Group 

(c). 

First  count  made 

Second  count  made 

Corpuscle  gain  or  loss. 

Col.  index 

gain  or 

loss. 

ansesthesia. 

before  anaesthesia. 

Gain. 

Loss. 

5 

5,340,000 

5,370,000 

30,000 

0.005 

16 

3,680,000 

5,230,000 

1,550,000 

0.278 

21 

5,560,000 

5,800,000 

240,000 

0.008 

Average  gain  740,000 

Average  loss  0.097 

Group 

{d). 

First  count  made 

Second  count  made 

Corpuscle  gain  or  loss. 

Col.  index 

some  time  before 

some  time  after 

^ 

, 

gain  or 

anaesthesia. 

anaesthesia. 

Gain. 

Loss. 

loss. 

1 

3,245,000 

3,920,000 

675,000 

0.13 

2 

4,170,000 

5,390,000 

1,220,000 

0.158 

3 

3,795,000 

4,330,000 

535,000 

0.147 

4 

4,050,000 

5,160,000 

1,110,000 

0.10 

15 

5,210,000 

5,360,000 

150,000 

0.073 

17 

4,160,000 

3,900,000 

260,000 

0.071 

20 

4,710,000 

5,925,000 

1,215,000 

0.136 

24 

3,970,000 

3,890,000 

80,000 

0.036 

31 

4,880,000 

5,360,000 

480,000 

0.018 

39 

3,900,000 

4,060,000 

160,000 

0.149 

Average  gain  520,500 

Average  loss  0.102 

Leucocytes.     The  number  of  leucocytes  varied  greatly  before 
and    after    the    operation.     The    average    count   preceding   the 


BLOOD    CHANGES    INDUCED     BY    ETHER.  9I 

operation  was  9898,  and  the  average  count  following  was 
14,484,  showing  an  average  gain  of  4586  per  cubic  millimetre. 
In  forty-three  instances  the  leucocytes  were  increased,  while  in 
five  instances  the  number  was  decreased  after  the  operation. 

Classification  of  Cases. 

So  as  to  carefully  compare  the  blood  disturbances  it  was 
found  necessary  to  group  the  cases  into  four  classes.  This  was 
done  in  order  to  find  what  bearing  the  preparatory  and  post- 
operative measures  associated  with  the  an?esthetic  period  have 
upon  the  blood  disturbances.  In  group  A  those  cases  are 
included  in  which  the  first  blood  examination  was  made  a  short 
time  before  anaesthesia  (average,  two  hours  and  twenty-one 
minutes)  and  soon  after  ansesthesia  (average,  four  hours  and 
forty-one  minutes).  The  cases  included  in  group  b  were  those 
in  which  the  blood  examinations  were  made  a  short  time 
before  the  operation  (average,  two  hours  and  fifty-one  minutes) 
and  some  tiitie  after  (average,  twenty  hours  and  fifty- nine 
minutes).  The  cases  in  group  c  include  those  in  which  the 
blood  examination  was  made  some  time  preceding  the  opera- 
tion (average,  four  hours  and  sixteen  minutes)  and  soon  after 
(average,  four  hours  and  sixteen  minutes).  The  cases  included 
in  group  d  were  those  in  which  the  blood  examination  was 
made  a  considerable  time  before  (average,  forty-one  hours  and 
one  minute)  and  some  time  after  the  operation  (average,  twenty 
hours  and  three  minutes). 

In  group  a  the  result  of  the  examination  represents  the 
changes  that  immediately  follow  the  anaesthetic  state,  the  first 
blood-count,  however,  being  made  after  the  preparatory  meas- 
ures of  treatment  had  been  instituted,  and  the  second  count 
before  the  post- operative  treatment  had  been  fairly  begun.  In 
group  b  the  results  in  a  general  way  show  the  effects  of  the 
anaesthetic  state  and  the  post-operative  treatment.  The  count 
preceding  the  operation  was,  however,  made  during  or  at  the 
height  of  the  preparatory  treatment.  In  group  c  the  results  rep- 
resent the  blood  changes  which  occur  during  the  preparatory 
treatment   and   during   the  ann^isthetic   state.     In  group  B  the 


92  DA  COSTA    AND    KALTEYER, 

results  include  the  effects  produced  by  the  preparatory  treat- 
ment, the  anti2Sthetic  state,  and  the  post-operative  measures. 
Fifteen  cases  were  included  in  group  «,  22  in  group  b,  3  in 
group  <:,  and  10  in  group  d. 

Number  of  Erythrocytes.  The  average  gain  per  cubic  milli- 
metre in  the  number  of  erythrocytes  in  group  a  was  265,000; 
12  cases  in  this  class  showed  a  gain  in  the  number  of  colored 
corpuscles,  while  there  was  a  loss  in  3  cases. 

The  average  gain  per  cubic  millimetre  in  group  b  was 
460.204  corpuscles,  and  there  was  an  increase  in  the  number  of 
erythrocytes  in  18  cases  and  a  decrease  in  4  cases. 

The  average  gain  per  cubic  millimetre  in  group  c  was 
740,000  corpuscles.  Every  case  in  this  group  showed  an  in- 
crease in  the  number  of  red  cells. 

In  group  d  the  average  gain  was  520,500  corpuscles  per 
cubic  millimetre;  8  cases  showed  an  increase  in  the  number  of 
chromocytes,  and  2  cases  showed  a  decrease. 

In  series  a  Cases  Nos.  9,  40,  and  45  and  in  series  b  Cases 
Nos.  II,  14,  19,  and  38  indicate  that  the  preparatory  treatment 
produced  marked  concentration  of  the  blood,  which  was  prob- 
ably at  its  height  at  the  time  of  the  first  examination  or  a 
short  while  after,  and  the  blood  became  somewhat  diluted  be- 
fore the  second  count  was  made.  In  the  remaining  cases  of 
series  a  and  b  the  marked  increase  in  the  number  of  ery- 
throcytes must  be  attributed  to  the  blood  inspissation.  In 
series  c  a  gain  in  the  number  of  chromocytes  only  was  noted. 
This  was  probably  due  to  the  fact  that  two  of  the  factors  which 
produce  blood  inspissation — namely,  preparatory  treatment  and 
sweating  during  the  anaesthetic  period — were  taken  into  consid- 
eration ;  the  first  count  was  made  before  the  concentration.  In 
series  d  Cases  Nos.  17  and  24  show  that  the  equilibrium  exist- 
ing between  the  plasma  and  the  corpuscles  was  being  restored, 
for  the  reason  that  the  first  blood-counts  were  made  prior  to  the 
preparatory  treatment ;  the  figures  may  even  represent  an  abso- 
lute loss  of  chromocytes.  In  series  a  the  average  gain  of 
265,000  corpuscles  appears  to  represent  the  degree  of  concen- 
tration (over  the  inspissation  induced  by  the  preparatory  meas- 
ures) produced  during  the  anaesthetic  period.     In  series  b  the 


BLOOD     CHANGES     INDUCED     BY     ETHER. 


93 


average  gain  of  460,204  cells  per  cubic  millimetre  represents 
the  degree  of  concentration  produced  during  the  anesthetic  and 
post-aneesthetic  periods.  In  series  c  the  average  gain  of  740,000 
cells  per  cubic  millimetre  represents  the  concentration  produced 
by  the  preparatory  measures  of  treatment  and  the  anaesthetic 
period.  It  will  be  noticed  that  the  average  gain  in  series  c  is 
greater  than  in  any  of  the  other  groups.  The  explanation  for 
this  is  probably  that  the  period  preceding  the  operation  and  the 
anaesthetic  stage  produced  the  highest  degree  of  inspissation. 
In  series  c  the  average  gain  was  520,500  per  cubic  millimetre. 
This  increase  in  the  number  of  corpuscles  represents  the  degree 
of  inspissation  produced  by  the  three  periods.  It  is  apparent, 
however,  that  this  gain  is  not  so  striking  as  the  gain  in  series  c, 
probably  for  the  reason  that  blood  dilution  has  been  active 
in  some  of  the  cases  before  the  last  examination. 

Hcsmoglobin.  The  haemoglobin  gain  and  loss  when  analyzed 
in  regard  to  the  four  periods,  a,  b,  c,  and  d,  shows  varying 
results.  In  some  instances  the  haemoglobin  appears  to  have 
increased ;  this  apparent  increase  being  due  to  blood  concen- 
tration. In  some  instances  the  hemoglobin  appears  to  have 
decreased.  This  necessarily  represents  an  absolute  decrease. 
When  the  total  blood  value  is  fluctuating  the  gain  and  loss  of 
hemoglobin  is  best  determined  by  studying  the  individual 
corpuscular  value  in  haemoglobin. 


Duration  of 

^0. 

operation. 

37 

90  minutes 

41 

75 

13 

65 

6 

60 

9 

60 

36 

38 

29 

37 

40 

35 

13 

30 

45 

30 

44 

25 

49 

25 

8 

24 

10 

23 

7 

12 

Table  IV. 

rt  time  before  and 

soon  after  anaesthesia. 

Corpuscular 

gain  or  loss. 

Loss  of  color 
index. 

Gain. 

Loss. 

820,000 

0.091 

70,000 

+ slight 

990,000 

0.203 

120,000 

0.026 

130,000 

0.052 

635,000 

0.02 

420,000 

0.104 

210,000 

0.024 

660,000 

0.032 

470,000 

0.059 

450,000 

0.09 

200,000 

0.105 

170,000 

0.0S4 

430,000 

0.132 

25,000 

0.06 

94 


DA  COSTA    AND     KALTEYER, 


(6)  Blood  examinations  made  a  short  time  before  and  some  time  after 

anaesthesia. 


Duration  of 

Corpuscular  gain  or  loss. 

Loss  of  color 
in(l6x. 

so. 

opcrRtion.                                      ■ — 

Gain. 

Loss. 

19 

90  minutes 

290,000 

0.002 

33 

83 

600,000 

0.219 

50 

73 

140,000 

0.038 

30 

67 

1,305,000 

0.034 

26 

65 

90,000 

0.129 

28 

65 

700,000 

0.082 

32 

60 

1,140,000 

0.035 

42 

55 

380,000 

0.213 

25 

48 

1,210,000 

0.026 

34 

45 

930,000 

0.058 

35 

45 

680,000 

0.162 

46 

45 

1,160,000 

0.11 

11 

40 

260,000 

0.001 

43 

40 

480,000 

0.201 

22 

38 

690,000 

0.065 

38 

30 

750,000 

0.008 

23 

28 

820,000 

0.118 

12 

27 

12,500 

0.174 

27 

25 

317,000 

0.040 

47 

25 

420,000 

0.081 

48 

20 

240,000 

0.098 

14 

18 

170,000 

0.022 

(e)  Blood  examinations  made  some  time  before  and  soon  after  anjesthesia. 

Corpuscular  gain  or  loss. 


No. 

21 

5 

16 


Duration  of 
operation. 

105  minutes 
55 
19 


Gain. 
240,000 
30,000 
1,550,000 


Loss. 


Loss  of  color 
index. 

0.008 
0.005 
0.278 


(d)  Blood  examinations  made  some  time  before  and  some  time  after 
anaesthesia. 


Duration  of 

Corpuscular  gain  or  loss. 

Loss  of  CO 

'0. 

operation.                                      r-                -a.       _ 

Gain.                  Loss. 

index. 

3 

120  minutes      .         .         .         535,000 

0.147 

4 

120 

1,110,000 

0.10 

20 

95 

1,215,000 

0.136 

15 

90 

150,000 

0.073 

39 

90 

160,000 

0.149 

17 

60 

260,000 

0.071 

2 

47 

1,220,000 

0.158 

1 

35 

675,000 

0.13 

24 

35 

80,000 

0.036 

31 

25 

480,000 

O.OIS 

BLOOD    CHANGES     INDUCED    BY    ETHER. 


95 


Table  V. 

(a)  Blood  examinations  made  a  short  time  before  and  soon  after 
anaesthesia. 


No. 


Amount  of  ether  used. 


18 

270 

29 

270 

41 

255 

9 

60 

180 

37 

240 

6 

210 

36 

165 

13 

7.8 

144 

10 

150 

40 

150 

45 

150 

8 

135 

49 

120 

44 

75. 

7 

7.2 

c. 


Corpuscular 

gain  or  loss. 

Loss  of  color 

, ^. 

index. 

Gain. 

Loss. 

660,000 

0.032 

420,000 

0.104 

70,000 

+  slight 

130,000 

0.052 

820,000 

0.091 

120,000 

0.026 

635,000 

0.02 

990,000 

0.203 

430,000 

0.132 

210,000 

0.024 

470,000 

0.059 

170,000 

0.084 

200,000 

0.105 

450,000 

0.09 

45 


25,000 


0.06 


(6)  Blood  examinations  made  a  short  time  before  and  some  time  after 

anaesthesia. 


No. 


Amount  of  ether  used. 


33 

405    c.c 

32 

360     " 

11 

240     " 

26 

240     " 

43 

240     " 

50 

240     " 

19 

225     " 

22 

195     " 

42 

195     " 

25 

180     " 

28 

180     " 

34 

154     " 

30 

143     " 

12 

7.2 

128     " 

23 

135     " 

38 

120     " 

27 

105     " 

46 

90     " 

47 

90     " 

48 

75     " 

14 

6.0 

45     " 

35 

30     " 

Corpuscular  gain  or  loss. 

Loss  of  color 

Gain. 

Loss. 

600,000 

0.219 

1,140,000 

0.035 

260,000 

0.001 

90,000 

0.129 

480,000 

0.201 

140,000 

0.038 

290,000 

0.002 

690,000 

0.065 

380,000 

0.213 

1,210,000 

0.026 

700,000 

0.082 

930,000 

0.058 

1,305,000 

0.034 

12,500 

0.174 

820,000 

0.118 

750,000 

0.008 

317,000 

0.040 

1,160,000 

0.11 

420,000 

0.081 

240,000 

0.098 

170,000 

0.022 

680,000 

0.162 

96 


DA  COSTA    AND    KALTEYER, 


(c)  Blood  examinations  made  some  time  before  and  just  after  anaesthesia. 

Corpuscular  gain  or  loss. 


No.  Amouut  of  ether  used. 

21  230  C.C. 

5  188  "  . 

16  103  "  . 


Gain. 
240,000 
30,000 
1,550,000 


Loss. 


Loss  of  color 
index. 

0.008 
0.005 
0.278 


{d)  Blood  examinations  made  some  time  before  and  some  time  after 

anaesthesia. 


No. 


Amount  of  ether  used. 


3 

720 

c.c. 

39 

330 

1 

195 

20 

180 

2 

165 

4 

165 

31 

150 

24 

120 

17 

105 

15 

75 

Corpuscular 

gain  or  loss. 

Loss  of  color 
index. 

Gain. 

Loss. 

535,000 

0.147 

160,000 

0.149 

675,000 

0.13 

1,215,000 

0.136 

1,220,000 
1,110,000 

0.158 
0.10 

480,000 

0.018 

80,000 
260,000 

0.066 
0.071 

150,000 

0.073 

Color  Index.  In  that  series  in  which  the  blood  was  examined 
just  before  and  soon  after  the  anaesthetic  stage,  the  color  index 
value  was  reduced  in  every  case  but  one.  The  average  loss  of 
color  index  in  this  series  was  0.077.  This  seems  to  clearly 
demonstrate  that  there  was  marked  blood  destruction  and  also 
increased  blood  production  during  the  period  of  anaesthesia. 
These  conditions  are  indicated  by  the  loss  in  the  average,  the 
newly  formed  erythrocytes  being  deficient  in  coloring  matter. 
Although  the  blood  was  concentrated,  the  individual  hemo- 
globin value  fell. 

In  every  instance  in  series  b  the  color  index  was  reduced. 
The  average  loss  of  color  value  was  o  084.  The  average  loss 
in  series  b  was  more  marked  than  the  average  loss  in  series  a, 
the  reason  for  this  probably  being  that  rapid  haemogenesis  (of 
cells  deficient  in  hciemoglobin)  progressed  over  a  longer  period, 
as  the  second  blood-count  was  made  some  time  after  the  termina- 
tion of  the  ancusthetic  state.  Therefore  the  average  color  value 
reduction  was  more  pronounced. 

In  series  c  the  average  loss  of  color  index  was  0.O97. 

In    series  d  the  loss  in  the  blood  decimal  was   most   pro- 


BLOOD    CHANGES    INDUCED     BY    ETHER.  97 

nounced — the  average  fall  was  o.  102.  The  explanation  of  this 
marked  decrease  is  the  same  as  that  given  for  the  changes  in 
series  ^,  namely,  that  erythrocytic  regeneration  was  further 
advanced. 

The  constant  loss  in  the  color  index  is  the  most  convincing  evi- 
dence of  rapid  blood  destruction.  This  loss  in  the  color  value 
occurred  in  groups  a,  b,  c,  and  d.  In  only  one  instance,  in 
group  a,  was  there  a  slight  gain.  In  every  other  instance 
there  was  a  loss  in  the  corpuscular  haemoglobin  value.  If 
the  blood  disturbance  was  due  simply  to  concentration,  the 
rise  and  fall  in  the  number  of  corpuscles  and  the  percentage  of 
the  haemoglobin  should  have  been  parallel,  and  the  color  index 
would  not  have  been  changed.  The  reduction  in  the  color  value 
of  the  corpuscles  suggests  rapid  haemocytolysis  and  increased 
haemogenesis. 

The  Duration  of  the  Operation  and  the  Quantity  of  Ether 
Employed. 

The  results  do  not  seem  to  show  any  direct  relationship 
between  the  blood  disturbance  and  the  duration  of  the  opera- 
tion. A  similar  statement  may  be  made  in  regard  to  the  quan- 
tity of  ether.  Of  course,  it  is  obvious  that  a  prolonged  operation 
upon  a  sound  and  vigorous  patient  will  be  tolerated  better  than 
even  a  brief  operation  upon  one  who  is  weak  and  exhausted, 
and  also  that  some  individuals  will  have  much  less  blood  destruc- 
tion from  the  administration  of  a  large  quantity  of  ether  than 
others  will  from  the  inhalation  of  a  small  quantity.  On  account 
of  the  many  modifying  factors  it  is  difficult  to  determine  the 
exact  influence  which  the  quantity  of  ether  and  the  duration  of 
the  operation  have  upon  the  blood  changes. 

Blood  Loss.  The  blood  loss  was  very  slight  in  nearly  all  of 
the  cases ;  and  in  some  there  was  practically  no  loss  at  all  (eye 
operations).  It  appears  that  the  amount  of  blood  lost  did  not 
affect  the  blood  changes  to  a  perceptible  degree.  In  Cases  Nos. 
7,  9,  and  13,  in  group  a,  and  Cases  Nos.  12  and  14,  in  group 
b,  chloroform  was  used  in  conjunction  with  the  ether.  The 
amount  of  chloroform  employed  was  very  small. 

Am  Surg  7 


98 


DA  COSTA    AND     KALTEYER, 


(a)  Blood  examinations  made  a  sliort  time  before  and  soon  after 
ansesthesia. 


Corpuscular  gain  or  loss. 

Loss  of  color 

No. 

Blood  loss. 

Gain. 

Loss. 

index. 

6 

loO  c.c.   . 

120,000 

0.026 

41 

120    "... 

70,000 

4-sliglit 

9 

90    "... 

130,000 

0.052 

18 

90    "... 

660,000 

0.032 

49 

90    "     . 

200,000 

0.105 

7 

80    "... 

25,000 

0.06 

8 

15    "... 

170,000 

0.084 

37  ' 

15    '•     . 

820,000 

0.091 

13 

Small  amount 

990,000 

0.203 

10 

Minimum 

430,000 

0.132 

29 

Bloodless 

420,000 

0.104 

40 

Bloodless 

210,000 

0.024 

36 

Bloodless 

635,0(t0 

0.02 

44 

Bloodless 

450,000 

0.09 

45 

Bloodless 

470,000 

0.059 

{b)  Blood  examinations  made  a  short  time  before  and  some  time  after 

anaesthesia. 


Xo. 

Blood  loss 

11 

120  c.c.   . 

19 

120    "     . 

48 

120    "     . 

26 

90    "     . 

22 

60    "     . 

35 

60    "     . 

42 

60    "     . 

47 

60    "     . 

23 

30    "     . 

25 

30    '•     . 

28 

30    "     . 

38 

30    "     . 

46 

30    "     . 

50 

30    "     . 

43 

15    i'     . 

32 

15    "     . 

12 

Small      . 

33 

Small      . 

34 

Trivial    . 

30 

Very  slight 

14 

Bloodless 

27 

Bloodless 

Corpuscular  gain  or  loss. 

Loss  of  color 

index. 

Gain. 

Loss. 

260,000 

0.001 

290,000 

0.002 

240,000 

0.098 

90,000 

0.129 

690,000 

0.065 

680,000 

0.162 

380,000 

0.213 

420,000 

0.081 

820,000 

0.118 

1,210,000 

0.026 

700,000 

0.082 

750,000 

0.008 

1,160,000 

0.11 

14(t,000 

0.038 

480,000 

0.201 

1,140,000 

0.035 

12,500 

0.174 

600,000 

0.219 

930,000 

0.058 

1,305,000 

0.034 

170,000 

0.022 

317,000 

0.040 

{c)  Blood  examinations  made  some  time  before  and  soon  after  anaesthesia. 

Gain.  Loss. 


No. 

Blood  loss 

21 

240  c.c.   . 

5 

()( 1    "     . 

16 

15    "     . 

Corpuscular  gain  or  loss. 

Loss  of  color 
index. 

240,000 

0.008 

30,000 

0.005 

1,550,000 

0.278 

BLOOD    CHANGES    INDUCED    BY    ETHER. 


99 


[d)  Blood  examinations  made  some  time  before  and  some  time  after 

aniesthesia. 


No. 

Blood  loss 

3 

478  c.c.   . 

4 

300    "     . 

20 

240    "     . 

2 

90    "     . 

24 

60    "     . 

lo 

30    "     . 

39 

30    '•     . 

31 

15    "     . 

1 

Slight     . 

17 

Verv  little 

Corpuscular  gain  or  loss 


Gain. 

.").">.'),  000 

], 110,001) 

1,215,000 

1,220,000 

1.50,000 
100,000 
480,000 
075,000 


Loss. 


80,000 


200,000 


Loss  of  color 
index. 

0.147 

0.10 

0.136 

0. 1.58 

0.036 

0.073 

0.149 

0.018 

0.13 

0.071 


An  Experiment  upon  an  Animal. 

The  constant  fall  in  the  color  index  after  anaesthesia  suggested 
the  idea  of  experimental  study  in  this  line.  It  is  our  intention 
to  continue  this  work  from  an  experimental  stand-point.  We 
feel  that  the  single  experiment  which  has  been  performed  is 
worthy  of  mention,  although  we  do  not  attempt  to  draw  any 
positive  conclusions  from  a  solitary  observation.  Two  rabbits 
were  obtained,  almost  identical  in  point  of  age,  size,  and  appear- 
ance. One  animal  was  etherized  for  two  hours  and  twenty 
minutes,  150  c.c.  of  ether  being  employed  during  the  anaes- 
thetic period. 

A  blood  examination  ten  minutes  prior  to  the  beginning  of 
the  etherization  showed  6,140,000  erythrocytes  per  cubic  milli- 
metre; 79  per  cent,  haemoglobin,  and  a  color  index  of  0.693. 
The  second  blood-count  was  made  thirty-nine  minutes  after  the 
beginning  of  the  inhalation  of  the  ether.  This  examination 
showed  6,260,000  erythrocytes ;  69  per  cent,  haemoglobin,  and 
a  color  index  of  0.592.  The  third  examination  was  made  one 
hour  and  fifty  minutes  after  the  beginning  of  the  etherization. 
This  count  showed  7,000,000  erythrocytes  ;  haemoglobin,  69  per 
cent.,  and  a  color  index  of  0.485. 

The  animal  was  then  killed  with  ether. 


A  Summary  of  the  Post-mortem  Examination. 

The  serous  cavities  did  not  contain  free  fluid.     The  bladder 
contained  considerable  urine,  and  the  lower  portion  of  the  in- 


100  DA  COSTA    AND     KALTEYER, 

testinal  canal  contained  much  thin  fecal  matter.  The  spleen 
was  small.  The  bone-marrow  of  the  right  femur  was  bright 
red.  Sections  of  the  femur-marrow  were  fixed  in  Gulland's 
formalin  solution  (formal,  lo  per  cent,  in  absolute  alcohol). 
They  were  dehydrated  in  alcohol  and  infiltrated  in  paraffin. 
The  cut  sections  were  stained  with  Ehrlich's  triple  stain  (diluted 
with  four  times  its  volume  of  water)  for  five  minutes,  washed  in 
water,  then  treated  for  a  few  seconds  with  methylic  alcohol, 
dehydrated  in  alcohol,  cleared  in  xylol  and  mounted  in  Canada 
balsam.  Some  of  the  sections  were  stained  with  h?ematoxylin 
and  eosin. 

The  other  animal  was  killed  by  fracturing  the  spine.  Upon 
post-mortem  examination  all  of  the  serous  cavities  contained  a 
small  amount  of  fluid.  The  bone-marrow  of  the  right  femur 
was  not  so  red  as  was  the  marrow  of  the  etherized  animal,  and 
was  somewhat  firmer.  Pieces  of  this  marrow  were  treated 
similarly  to  the  marrow  of  the  etherized  animal.  Upon  micro- 
scopical examination,  by  contrasting  the  marrow  of  the  ether- 
ized animal  and  the  non-etherized,  it  appears  that  in  the  former 
instance  there  is  a  marked  cell  proliferation,  the  cells  being  very 
numerous  and  encroaching  upon  the  normal  fat  spaces  of  the 
marrow.  The  cell  proliferation  in  the  marrow  of  the  etherized 
rabbit  involves  particularly  the  erythroblastic  elements  ;  these 
cells  are  very  numerous.  These  changes  are  exhibited  in 
Figs.  I  and  2. 

As  previously  stated,  we  hesitate  to  draw  any  conclusion  from 
this  single  experiment,  but  nevertheless  the  very  marked  changes 
that  were  found  are  suggestive  of  erythroblastic  proliferation 
as  a  result  of  the  administration  of  ether.  In  the  light  of  this  ex- 
periment it  might  be  well  to  inquire  if  the  pains  in  the  limbs  and 
back,  so  common  after  antX-sthetization,  are  not  due,  at  least  in 
part,  to  changes  in  the  marrow. 

We  must  not  omit  mentioning  that  the  blood  for  examina- 
tion was  taken  from  the  ear,  and  that  during  the  entire  an;cs- 
thetic  state  probably  10  c.c.  of  blood  were  lost,  so  that  the 
changes  found  in  the  marrow  might  be  in  part  due  to  the 
hemorrhage. 


Fig.  1. 


Section  of  normal  bone  marrow  of  femur  (of  rabbit). 


Fig.  2. 


Section  of  bone  marrow  of  femur  (of  rabbit)  showing  marked  erythroblastic 
proliferation  after  death  by  etherization. 


blood   changes    induced   by   ether.  loi 

Conclusions. 

1.  The  number  of  red  corpuscles  is  influenced  by  many  fac- 
tors associated  with  and  accompanying  the  anaesthetic  state. 
The  character  of  this  change  is,  as  a  rule,  a  polycythaemia, 
rarely  an  oligocythremia.  These  factors  associated  with  and 
accompanying  the  anresthetic  state  may  be  grouped  in  three 
classes,  each  of  which  when  analyzed  separately  is  capable  of 
producing  an  increase  in  the  number  of  colored  corpuscles. 

2.  The  nature  of  this  polycythaemia  seems  best  explained 
by  a  lessening  of  the  watery  elements  of  the  plasma,  thereby 
reducing  the  total  volume  of  the  liquor  sanguinis,  and  conse- 
quently causing  concentration  of  the  blood.  It  seems  reason- 
able to  infer  that  the  polycythaemia  is  not  influenced  by  exces- 
sive proliferative  change  which  probably  occurs  in  hrematopoetic 
tissues.  The  increased  blood  production  is  an  effort  of  nature 
to  rapidly  restore  the  destroyed  cells. 

3.  The  three  periods  or  factors  incident  to  the  polycythaemia 
are :  (a)  The  period  of  preparatory  operative  treatment ;  (b) 
the  anaesthetic  state,  and  (c)  the  post-operative  state. 

4.  The  blood  inspissation  is,  as  a  rule,  most  pronounced  im- 
mediately after  the  termination  of  the  anaesthetic  stage.  (See 
group  c.)  In  some  instances  the  anhydraemia  may  be  in- 
creased by  each  succeeding  factor,  or  one  of  these  factors  may 
exceed  the  other ;  for  example,  the  preparatory  measures  may 
bring  about  such  a  high  grade  of  concentration  that  during  the 
period  of  anesthesia  the  polycythaemia  may  be  stationary,  or 
in  a  few  hours  may  lessen  somewhat.  This  variation  existing 
between  the  plasma  and  the  corpuscles,  although  temporary — 
for  the  economy  adjusts  the  balance  of  the  output  and  the 
intake  of  the  watery  principles  of  the  blood  with  wonderful 
rapidity — should  be  regarded  as  too  pronounced  to  be  within 
the  physiological  limits.  The  relative  increase  in  the  number 
of  erythrocytes  is  generally  still  present  some  time  after  the 
operation  (see  group  d) ;  but  not  infrequently  the  adjustment 
of  the  watery  and  solid  elements  manifests  itself  before  this 
time,  and  an  oligocythjtmia  may  be  present. 


I02  DA  COSTA    AND    KALTEYER, 

5.  The  haemoglobin  is  always  reduced  absolutely;  in  some 
instances  there  is  an  apparent  increase,  but  this  rise  in  the  per- 
centage of  haemoglobin  is  never  parallel  with  the  rise  in  the 
number  of  red  blood  cells.  The  individual  corpuscular  h;t2mo- 
globin  value  is  therefore  reduced.  This  reduction  in  the  color 
value  of  the  chromocytes  is  most  striking  when  the  color  index, 
ascertained  some  time  before  the  operation,  is  compared  with 
the  blood  decimal,  determined  some  time  after  the  operation. 
We  must  conclude  that  etherization  produces  increased  hcEmolysis, 
and  in  nature's  effort  to  rapidly  replace  the  destroyed  corpjtscles, 
the  regenerated  cells  are  imperfectly  supplied  xvith  hcEinoglobin. 

6.  The  duration  of  the  anaesthetic  state  and  the  amount  of  ether 
may  influence  the  blood  changes  ;  but  the  extent  of  the  disturb- 
ances could  not  be  determined  on  account  of  the  many  modify- 
ing factors. 

7.  The  amount  of  blood  loss  as  encountered  in  this  series  of 
cases  does  not  seem  to  demonstrably  affect  the  results. 

8.  Whenever  possible  one  or  more  blood  examinations  should 
be  made  before  giving  a  general  anaesthetic,  and  the  examina- 
tions should  be  made  before  preparatory  treatment  has  been 
instituted. 

On  account  of  the  haemolysis  which  is  shown  by  the  fall  in 
corpuscular  haemoglobin  after  operation,  a  very  low  percentage 
of  haemoglobin  must  be  regarded  as  a  contraindication  to 
operation.  The  amount  which  should  be  regarded  as  a  posi- 
tive contraindication  is  uncertain.  We  think  with  Hamilton 
Fish,  that  below  50  per  cent,  is  a  dangerous  level.  In  malig- 
nant diseases,  and  in  cases  where  surgery  might  prolong  life  but 
cannot  cure,  operation  should  not,  as  a  rule,  be  performed  under  a 
general  anaesthetic  if  haemoglobin  is  below  50  per  cent.  We 
have  operated  in  two  cases  in  which  the  haemoglobin  was  40 
per  cent.  In  each  instance  a  vital  emergency  existed,  and  in 
each  case  death  upon  the  table  was  narrowly  averted.  Mikulicz 
sets  30  per  cent,  as  the  lowest  level  at  which  operation  is  to  be 
attempted.  We  would  not  give  a  general  an;esthetic  except 
under  the  stress  of  absolute  necessity,  if  the  haemoglobin  is 
below  40  per  cent.     It  is  true  cases  are  occasionally  an.xsthe- 


BLOOD    CHANGES    INDUCED    BY    ETHER.  IO3 

tized  with  success  when  there  is  less  than  40  per  cent.  We 
know  of  one  case  with  30  per  cent,  anzesthetized  successfully, 
and  of  another  with  only  24  per  cent. ;  but  a  few  exceptions  do 
not  disprove  the  rule.  In  cases  with  haemoglobin  below  50  per 
cent.,  if  an  operation  is  necessary,  a  local  anzesthetic  should  be 
used  whenever  possible. 

Whenever  the  percentage  of  haemoglobin  is  low,  if  an  opera- 
tion is  determined  on,  the  ordinary  preparatory  measures  should 
be  modified  in  every  way  in  order  to  avoid  creating  an  undue 
drain  upon  the  blood.  If  a  general  anaesthetic  is  given  its 
administration  should  be  intrusted  to  an  experienced  man;  as 
little  as  possible  should  be  given,  and  in  many  instances  oxygen 
should  be  combined  with  it.  The  operation  should  be  per- 
formed rapidly ;  prompt  measures  should  to  taken  to  bring 
about  reaction  after  its  completion,  and'  oxygen  should  be 
inhaled  to  remove  ether  quickly  from  the  lungs  and  blood. 


STUDIES  OF  THE  BLOOD   IN  ITS  RELATION  TO 
SURGICAL  DIAGNOSIS. 

By  R.  C.  CABOT,  M.D.,  J.  C.  HUBBARD,  M.D., 

AND 

J.  B.  BLAKE,  M.D., 

BOSTON. 


Among  the  problems  which  we  undertook  to  investigate  dur- 
ing the  preparation  of  this  paper  sufficient  material  has  for  valid 
inferences  been  secured  only  in  four,  viz.  : 

1.  The  effects  of  ether  upon  the  leucocyte-count. 

2.  The  effects  of  operation  upon  the  leucocyte-count, 

3.  The  effects  of  fractures  upon  the  leucocyte-count. 

4.  The  regeneration  of  the  blood  after  operations  for  malig- 
nant disease. 

We  shall  present,  however,  some  observations  on  the  varia- 
tions of  the  white-count  in  typhoid  fever  and  after  muscular 
exertion,  which  seem  to  us  of  interest. 

I.  Leucocvtosis  after  Ether.  The  importance  of  deter- 
mining whether  leucocytosis  is  increased  by  ether  narcosis  is 
obvious  in  the  post-operative  treatment  of  surgical  cases.  Dur- 
ing this  period  the  temperature-chart  and  leucocyte-count  are 
sometimes  consulted  for  information  regarding  the  progress  of 
the  healing  process  and  the  possibility  of  septicaemia  or  of 
deep-seated  pockets  of  pus.  It  is  obvious  that  if  we  are  to  draw 
any  conclusions  from  the  leucocyte-count  we  must  know,  first, 
whether  ether  per  se  has  any  tendency  to  produce  leucocytosis  ; 
and,  secondly,  how  much,  if  at  all,  the  leucocytes  are  affected 


BLOOD    IN    ITS    RELATION    TO    SURGICAL    DIAGNOSIS.       IO5 

by  the  operation  itself  aside  from  its  later  results.  To  deter- 
mine these  facts  we  have  had  the  leucocytes  counted : 

(a)  Before  the  ether  was  administered. 

(d)  After  full  anaesthesia,  or  before  the  beginning  of  the  oper- 
ation. 

(c)  After  operation. 

In  this  way  we  have  investigated  50  cases.  In  a  general  way 
our  results  tend  to  show  that  there  is  little  if  any  leucocytosis 
during  the  period  just  after  full  etherization  and  just  before  the 
beginning  of  the  operation,  while  after  the  operation  there  is 
not  infrequently  a  moderate  increase  of  the  white  cells.  Out 
of  the  total  50  cases  only  13  showed  an  increase  of  more  than 
2000  leucocytes  after  full  anaesthesia,  while  in  seven  there  was 
an  actual  diminution  in  the  leucocyte-count.  The  onh' cases  in 
which  there  was  considerable  increase  after  etherization  are  the 
following  : 


No. 

Operation 

Before  ether. 

After  ether 

1. 

Hernia 

9,400 

12,400 

2. 

Hernia 

8,200 

13,600 

3. 

Hernia 

6,800 

9,400 

4. 

Stone  in  the  bladder 

15,800 

19,920 

5. 

Cancer  in  the  cervix 

12,400 

17,000 

6. 

Ovariotomy 

^ 

13,800 

21,000 

7. 

Vaginal  section 

14,600 

25,000 

These  results  are  in  sharp  contrast  with  those  of  Chadbourne, 
who  studied  21  cases  and  found  an  increase  in  every  case,  the 
average  being  37  per  cent.  He  noted,  however,  that  the  leuco- 
cytosis was  most  marked  during  the  Jirst  part  of  etherization^ 
and  that  the  increase  was  exceedingly  rapid,  some  cases  show- 
ing a  change  of  70  per  cent,  within  a  few  minutes.  Very  pos- 
sibly the  subsequent  fall  toward  the  completion  of  the  anaes- 
thesia may  have  been  equally  rapid.  The  differential  counts  in 
Chadbourne's  cases  showed  that  all  varieties  of  leucocytes  were 
increased,  the  lymphocytes  somewhat  more  than  the  others. 
Chadbourne  considers  the  leucocytosis  to  be  due  to  the  irrita- 

'  Philadelphia  Medical  Journal,  February  i8,  1899. 


io6 


CABOT,    HUBBARD    AND     BLAKE, 


tion  produced   by  the  ether  vapor  upori   the   respiratory  tract. 
Exhibited  in  tabular  form,  our  results  are  as  follows : 

Table  I. — Leucocyte-count  before  and  after  Ether  Anaesthesia, 

AND   AFTER   OPERATION. 


:ases.  Operation. 

1.  Litliolapaxy    . 

2.  ?  .         . 

3.  Senile  gangrene 

4.  Cancer  cervix  uteri 


5.  Appendix 

6.  Stone  (kidney) 


7.  Excision  elbow 

8.  Ether  examination 

9.  Hernia   . 

10.  Laparotomy    . 

11.  Stricture  urethra     . 

12.  Hernia   . 

13.  Gastro-enterostomy 

14.  Cholecystotomy 

15.  Gastrostomy   . 

16.  Stricture  urethra     . 

Appendicitis  . 

Hernia   . 

Inguinal  hernia 

Appendicitis  . 

21.  Hernia,  inguinal     . 

22.  Abscess  of  rectum  . 
2.3.   Litholapaxy   . 

24.  Chronic  mastitis 

25.  Tumor  neck    . 

26.  Hernia    . 

27.  Empyema 

28.  Nephrectomy. 

29.  Enchondromata 

30.  Hernia   . 

31.  Amputation  leg 

32.  8upra[)ubic  cystotomy 

33.  Necrosis  tibiie 


Count 

Count  after 

before 

ether  but 

Count  after  operation. 

ether. 

before  operation. 

.      15,800 

19,920 

19,300  same  day. 
15,400  next  morning 

.       6,000 

8,600 

16,600  same  day. 
11,120  next  morning 

.     17,200 

13,600 

19,900  same  day. 
16,100  next  morning 

.     12,400 

17,060 

20,700  same  day. 
10,400  next  morning 

.     18,100 

17,520 

21,500  same  day. 
12,600  next  morning 

7,900 

7,200 

27,300  same  day. 
13,700  next  morning 

8,060 

9,100 

8,100  same  day. 

.     14,400 

10,200 

10,600          ' 

3, 660 

5,600 

10,900 

.     17.000 

17,400 

14,400 

6,0110 

6,400 

5,200 

5,400 

7,200          ' 

7,800 

7,600 

9,400 

8,000 

9,200 

8,600 

.       6,400 

8,000 

8,400 

.     10,000 

16,400 

16,000 

.       8,600 

10,800 

10,200 

.       9,000 

12,800 

13,400 

.       6,000 

7,200 

8,400          ' 

.     16,000 

15,800 

17,200          ' 

8,200 

13,600 

14,800 

.     10,000 

11,000 

11,000          ' 

7,600 

8,800 

.     14,800 

16,000 

16,600 

3,800 

4,600 

4,400 

.       9,400 

12,400 

11,800 

.       2,800 

23,000          ' 

.     15,400 

15,800 

21,200          ' 

.       10,600 

11,000 

14,0U(t 

6,800 

9,400 

.      10,000 

12,800 

8,600 

.     20,400 

22, 200 

22,800          ' 

.       8,800 

11,200 

11,800 

BLOOD    IN    ITS    RELATION    TO    SURGICAL    DIAGNOSIS. 


107 


Count 

Count  after 

Cast 

s.                 Operation. 

before 
ether. 

ether  but 
before  operation. 

Count  after  c 

)perati( 

34. 

Salpingitis 

9,200 

9,800 

13,000  same  day 

35. 

Laparotomy    . 

7,900 

11,800 

9,400 

36. 

Vaginal  section 

.       l.^.tilMI 

22,200 

20,000 

37. 

Vaginal  section 

14,000 

25,000 

21,600 

38. 

Vaginal  section 

8,000 

11,200 

8,600 

39. 

Laparotomy    . 

13,000 

15,000 

18,000 

40. 

Hysterectomy  (hemor'ge 

)       8,900 

10,000 

19,800 

41. 

Ovariotomy    . 

13,800 

21,000 

21,400 

12,200  next  day. 

42. 

Healthy  medical  studen 

t     10,200 

11,000 

9,400  same  day 

43. 

Ischiorectal  abscess 

8,200 

10,000 

44. 

Dilating  and  curetting 

12,500 

22,000 

45. 

Abscess  of  hand 

14,000 

20,000 

46. 

Ventral  suspension 

8,800 

24,000 

47. 

Cervix    . 

8,500 

9,200 

20,000 

48. 

Hemorrhoids  . 

7,500 

8,400 

14,500 

49. 

Cervix     . 

7,800 

10,400  ' 

21,400 

50. 

Vagina   . 

7,200 

8,000 

19,000 

51. 

Laparotomy    . 

8,200 

25,000 

52. 

Breast  amputation  . 

6,500 

21,600 

53. 

Vagina   . 

8,000 

24,000 

54. 

Amputation  cervix  . 

7,000 

8,800 

11,500 

55. 

Dilating  and  curetting 

6,800 

8,200 

19,400 

56. 

Tumor  nose     . 

8,800 

8,000 

8,400 

57. 

Healthy  medical  studen 

8,200 

9,600 

7,800 

2.  PosT-oPERATiVE  Leucocytosis.  After  operation  the  leu- 
cocyte-count was  increased  2000  or  more  in  35  out  of  47  cases, 
and  3000  or  more  in  27  cases.  This  increase  was  in  24  cases, 
or  one-half  of  all,  a  relatively  slight  one,  amounting,  on  the 
average,  to  not  more  than  20  per  cent.,  and  in  five  cases  there 
was  an  actual  decrease.  In  a  few  cases  leucocytosis  was  con- 
siderable, for  example  :  (a)  Case  of  stone  in  the  kidney  ;  before 
operation,  but  after  complete  etherization,  7200;  four  hours 
later,  after  operation,  27,300 ;  next  morning,  13,700.  Tempera- 
ture, 101°.  (<^)  Nephrectomy.  Before  operation,  but  after  ether, 
15,400.  After  operation,  21,200.  As  a  result  of  our  counts  in 
47  cases,  we  conclude  that  operation  has  by  itself  a  consider- 
able tendency  to  increase  the  leucocyte-count  in  about  one-half 
the  cases,  while  in  the  remaining  half  no  leucocytosis  of  im- 


I08  CABOT,    HUBBARD    AND    BLAKE, 

portance  occurs.  Regarding  the  duration  of  the  post-operative 
leucocytosis  which  occurred  in  our  cases  we  have  accurate  notes 
in  only  ten  cases.  In  these  it  appears  that  within  thirty-six 
hours  from  the  time  of  the  operation  the  post-operative  leuco- 
cytosis has  generally  disappeared.  In  7  of  our  ten  cases  the 
count  on  the  day  following  the  operation  was  lower  than  on  the 
morning  of  the  operation. 

3.  Fractures.  Experiments  have  shown  that  a  leucocytosis 
can  be  produced  in  animals  by  a  simple  fracture.  To  inves- 
tigate the  possibility  of  a  similar  leucocytosis  following  fractures 
in  human  beings,  we  have  made  32  counts  in  23  cases  of  simple 
fractures,  including  5  of  the  leg,  3  of  the  fibula,  2  of  the  ribs,  3 
of  the  radius,  i  of  the  patella,  i  of  the  pelvis,  i  of  the  spine,  i 
of  the  astragalus,  etc.  In  these  cases  there  are  10  showing  a 
leucocyte-count  of  more  than  10,500,  but  in  only  6  did  the  count 
reach  above  12,000.  The  highest  counts  were  15,400  in  frac- 
ture of  the  pelvis,  14,800  in  fracture  of  the  leg.  As  a  result  of 
these  counts  it  would  seem  that  simple  uncomplicated  fractures 
seldom  increase  the  leucocyte-count  to  any  considerable  extent. 
In  I  case  of  fracture  of  both  bones  of  the  leg  in  which  fat  em- 
bolism was  suggested  by  lung  symptoms  and  signs,  the  leuco- 
cyte-count rose  to  15,600,  falling  next  day  to  10,600.  In  one 
case  of  fracture  of  the  ribs  with  injury  to  the  lung,  the  count, 
made  two  days  after  the  injury,  showed  14,900  white  cells. 
A  compound  fracture  of  the  leg,  counted  two  hours  after  the 
injury,  showed  only  5400. 

Table  II. — Leucocyte-count  after  Fractures. 

Case.  Bones  broken.  Count.  Remarks. 

1.  ?         .         .         .       9,200  same  dav. 

10,200  next  day. 

2.  Fracture  nose         .         .         .     1-5,600  same  day. 

10,100  next  day. 

3.  Colle.s' fracture       .         .         .      10,800  same  day. 

4.  Fracture  tibia,  comp.      .  10,400  same  day. 

7,300  next  day. 

5.  Fracture  both  bones  leg  .       6,8011  same  day. 

5,(MM)  next  day. 

6 .         .         .       G,4(Ml  same  day. 

.'),9(H)  next  day. 


BLOOD    IN    ITS    RELATION    TO    SURGICAL    DIAGNOSIS.       IO9 


Cast 

'.                       Bones  broken. 

Count. 

/  . 

10,7<»0  same  day. 

S,4(K)  next  day. 

8. 

Fracture  tibula 

11,600  same  day. 
8,800  next  day. 

9. 

Both  bones  leg 

11,300  same  day. 
8,800  next  day. 

lit. 

Fracture  ribs 

7,900  same  day. 
8,100  next  day. 

11 

Fract.  clavicle,  ribs  and  scalp 

9,900  same  day. 
8,600  2dys.  later 

12. 

Fracture  astragalus 

10,800 

13. 

8,800 

14. 

Fracture  fibula 

11,200 

15. 

Fracture  patella     . 

9,6tK) 

16. 

Fracture  scapula    . 

12,500 

17. 

Fracture  leg  . 

13,100 

18. 

Fracture  astragalus 

11,400 

19. 

Fracture  fibula 

8,600 

20. 

Fracture  fibula 

13,600 

21. 

Fracture  pelvis       . 

15,400 

22. 

Fracture  spine        ... 

14,600 

23. 

Fracture  leg  .         .         .         • 

10,100 

24. 

Fracture  leg  . 

14,800 

25. 

Fr.  clavicle,  ribs,  and  injury  to 

lung        .... 

14,900 

26. 

Fracture  leg,  compound 

5,400 

27. 

Fracture  thigh 

14,260 

28. 

Fract.  arm,  comp.,  and  fract. 

scapula   .... 

13,000 

29. 

Fract.  skull,  scalp  wound 

12,100 

30. 

Greenstick  fract.  arm  (baby)  . 

15,200 

31. 

Impacted  hip          .         .         . 

11,600 

32. 

Impacted  fract.  leg 

6,600 

33. 

Impacted  hip  (4}  wks.  old)  . 

6,800 

34. 

Fracture  b.  b.  leg        (Feb.  2) 

15,600 

(Feb.  3) 

10,600 

35. 

Pott's  fracture 

5,850 

Remarks. 


No  ether,  2  days  later. 
No  ether,  2  hrs.  after. 
Ether. 

Ether. 
No  ether. 
Ether. 
Ether. 
No  ether. 

Fat  embolism  ? 


4.  Blood  Regeneration  after  Operations  for  Malignant 
Disease.  Bierfreund  ^  makes  the  astonishing  statement  that 
after  operations  for  malignant  disease  the  haemoglobin  never 
reaches  the  point  at  which  it  was  before  operation.  To  deter- 
mine the  correctness  of  this  curious  statement  we  examined 


1  Langenbeck's  Archiv,  vol.  xli. 


no 


CABOT,    HUBBARD    AND     BLAKE, 


thirteen  cases  of  cancer  and  arrived  at  results  wholly  opposed 
to  those  of  Bierfreund.  Thus,  in  a  case  of  cancer  of  the  breast, 
the  hjemoglobin  of  February  23d  was  70  per  cent.,  and  on 
March  i8th,  after  operation,  the  haemoglobin  was  85  per  cent., 
and  in  5  cases  entering  the  hospital  for  a  second  time  after  a 
recurrence  of  a  cancerous  growth,  the  haemoglobin  averaged  8j 
per  cent.     In  no  one  of  them  was  it  markedly  diminished. 


Table  III. — H.lmoglobix  Regeneratiox  after  Operatioxs  for 
Malignant  Growth. 


Case. 


Disease. 


1.  Mammary  cancer 

2.  Mammary  cancer 

3.  Cancer  uterus 


4.  Cancer  of  cervix 

5.  Recurrent  cancer  in  vagina 

after   hysterectomv  in 
August,'  190t». 

6.  Cancer  left  breast :  recurrence 


Hsemoglo- 

Haemoglo- 

bin before 

bin  after 

Time  elapsed. 

operation. 

operation. 

Per  cent. 

Per  cent. 

70 

70 

10  days. 

90 

80-80 

6  days. 

80 

90 

4  days.      This  case  simply 
curetting  and  cauterizing 
the  growth. 

90 

80 

10  days. 

90 

90 

6  days. 

90 


7.   Recurrent   cancer ;    second        90 
operation. 


8.  Cancer  breast 

9.  Cancer  breast     . 

10.  Cancer  uterus,  dermoid  ovary 

11.  Second  operation  for  osteo- 

sarcoma thigh. 

12.  Malig.  dis.  of  stomach,  ex- 

tensive cancer ;  explo.  lap. 

13.  Carcinoma  of  lip 


90 

90 

80 

80-90 

90 

100 

9(1 

50 


80 


90  Nov.  1896,  Oct.  1899,  re- 
current nodules;  removed 
May  and  November,  1900. 
Time  elapsed  6  days. 
90 —  8  days.  First  operation, 
Feb.  1901 1 ;  second  opera- 
tion, Nov.  1900. 

Second  oper.  May  2,  1899. 
Time  elapsed  8  days. 

Second  oper.  Dec.  1.  1900. 
Count  April  8. 

18  days. 
8  days. 

45         22  days.   General  condition 

worse. 
80  8  davs. 


5.  Variations  of  the  Counts  in  Cases  of  Typhoid  Fever 
Examined  from  Hour  to  Hour.  In  the  writings  of  Cushing, 
Thayer,  and  others  considerable  stress  has  been  laid  upon  the 
occurrence  of  a  short  wave  of  leucocytosis  as  suggestive  of 
perforation  of  the  intestine.   This  wave  of  leucocytosis  has  been 


BLOOD    IN    ITS    RELATION    TO    SURGICAL    DIAGNOSIS. 


I  I  I 


apparent  in  some  cases  only  when  hourly  or  half-hourly  counts 
were  made,  and  would  have  been  altogether  overlooked  had 
counts  been  made  only  once  or  twice  in  twenty-four  hours.  It 
appears  to  us  that  such  a  wave  of  leucocytosis  may  and  prob- 
ably does  occur  in  many  conditions  other  than  intestinal  per- 
foration and  even  without  any  recognizable  pathological  lesions. 
Thus,  in  a  convalescent  typhoid  were  recorded  the  following 
counts:  4.15  p.m.,  leucocytes,  10,100;  5.15  p.m.,  leucocytes, 
5800;  6.05  P.M.,  leucocytes,  9060.  In  a  healthy  subject,  aged 
thirty-one  years,  the  following  counts  were  recorded;  5.15  p.m., 
leucocytes,  5700;  5.30  p.m.,  leucocytes,  6600;  5.50  p.m.,  leuco- 
cytes, 7700 ;  605  P.M.,  leucocytes,  8400(50  far  is  to  be  observed 
a  steady  increase);  6.15  p.m.;  leucocytes,  5400. 

In  view  of  these  and  similar  variations  observed  in  10  other 
cases  (4  of  which  were  cases  of  typhoid  fever),  we  believe  it  is 
unsafe  to  base  any  inferences  regarding  diagnosis  and  treatment 
upon  such  temporary  zvaves  of  leucocytosis.  That  leucocy- 
tosis usually  exists  in  typhoid  perforation  we  are  well  aware, 
but  in  order  to  be  of  diagnostic  value  such  leucocytosis  must 
be  relatively  steady  and  not  of  the  type  described  by  Gushing. 


Table  IV. — Frequext  Leucocyte-counts  ix  Typhoid  Fever  axd 

IN  Health. 

Remarks. 
Several      hemorrhages     before, 
during  and  after  count.?. 

Xo  perforation.     Recovery. 

Steady  improvement  after  count, 


Case 

Diagnosis. 

Hour. 

Couut. 

1. 

Typhoid, 

11.00  A.  M. 

8,200 

12.00  ^i. 

10,300 

LOO  P.  M. 

12,200 

2.00     " 

10,300 

3.00     " 

11,400 

4.00     " 

15,400 

5.00     " 

7,500 

6.00     " 

7.00     " 

28,800 

8.00     " 

10,600 

2. 

Typhoid, 

Whites 

Entrance 

6,300 

8  dys.  later 

8,800 

9.20  A.  M. 

10.25     " 

14,300 

12.20  p.  M. 

12,800 

Boy,  15  years  ;  12  days'  duration 
at  entrance.  At  6  a.m.  sharp 
abdominal  pain  ;  no  vomiting; 
one   hour    later    cliill;    s.45. 


112 


CABOT,    HUBBARD    AND    BLAKE, 


Case 

.    Diagnosis. 

Hour. 

Count. 

Remarks. 

Sept.   15, 

1.20     " 

10,600 

slight   general   distention ;    7, 

2.20     " 

8,400 

subnormal,  anxious  expression; 

5.20     " 

10,600 

pain.     Parents  refused  opera- 

8.10    " 

14,300 

tion.     Sept.    17,   10.20  A.  M., 

10.00     " 

13,000 

died.      Symptoms   of   general 

Sept.   16, 

8.15  A.   M. 

20,200 

peritonitis. 

"       16, 

10.00     " 

22,000 

"       16, 

11.00  p.  M. 

18,800 

"       17, 

9.45  A.  M. 

9,000 

3. 

Typhoid. 

13,300 

Woman,  18  ■  6th  week  ;  sudden 

pain  and  swelling  leg  ;   phle- 

bitis. 

4. 

Typhoid, 

4,200 

Boy,    16  years  ;   admitted  Sept. 

8.30  A.  M. 

8,600 

14,  one  week's  duration ;  per- 

1.30 p.  M. 

5,500 

foration   Sept.    26th,   chill   at 

5.00     " 

3,200 

3.30  A.  M.  ;    transferred  surg. 

8.00     " 

5,000 

Operated  ;  lived  four  days ;  no 
general  peritonitis  at  operat'n. 

5. 

Typhoid, 

Hourly 

First 

6,400 

Five    days    before    hemorrhage 

Second 

6,600 

and  death. 

Third 

6,000 

6. 

Typhoid. 

3.45  p.  M. 
4.45     " 
5.35     " 

11,000 
9,060 
9,300 

7. 

Typhoid 

4.00  p.  M. 

15,000 

relapse, 

5.00     " 
5.50     " 

14,400 
11,400 

8. 

Convalescent 

4.15  p.  M. 

10,100 

typhoid. 

5.15     " 
6.05     " 

5,800 
9,060 

9. 

Typhoid, 

4.30  p.  M. 
5.20     " 
6.20     " 

7,100 
7,400 
5,600 

10. 

Typhoid, 

9.35  A.  M. 
10.00      " 
10.25     " 
11.25     " 

7,300 
5,100 
5,700 
6,850 

11. 

Typhoid, 

1.00  p.   M. 

2.(10     " 
3.00     " 

6,600 
6,600 
0,800 

BLOOD    IN    ITS    RELATION    TO    SURGICAL    DIAGNOSIS. 


113 


Count.  Remarks. 

11,000 

9,200 

7,000 
10,100 

5,700 

6,600 

7,700 

8,400 

5,400 

Severe  Muscular  Exertion. 
Finally,  we  think  it  may  be  of  interest  to  put  on  record  the 
following  observations  made  in  four  of  the  runners  in  a  recent 
"  Marathon  race  "  of  about  twenty-four  miles,  which  took  place 
April  19,  1901.  All  the  cases  showed  a  very  marked  increase 
in  the  white  cells.  In  one  case  the  leucocytes  rose  from  3700 
before  the  race  to  20,800  after  it.     (See  table  below.) 


Case.    Diagnosis. 

Uour. 

Normal  health, 

4.. 30  p.  M. 

4.45     " 

5.00     " 

5.15     " 

Normal  health, 

5. 15  p.  M. 

5.30     " 

5.50     " 

6.05     " 

6.15     " 

6.  Leucocytosis     after 

- 

DiflFerential  white  count  after  the  race 

Leucocytes  before 
race. 

Leucocytes 
after  race. 

Polymorph,  mona^and 
neutroph.       transit. 

Small 
mono. 

1 
o?S.     Myelocytes 

3  days  before,  1 

9800 ; 
immediately    | 
before,  4800^  J 

2  days  before,  \ 
5800^          / 

Immediately    "1 
before.  3700^  / 

3  days  before ) 

8.30  p.m.,      \ 

8200*         J 

14,400 

16,200 
20,800 

22,200 

■ 
90.3            4.0 

91.3  4.7 

84.4  8.0 

86.0            7.3 

5.7 

4.0 

7.2 

6.7 

0 

0 
0.4 

0 

0 

0 
0 

0 

^  Reds  normal ;  no  eosinophiles  found  in  two  coverslip  spreads ;  haemoglobin 
105  per  cent. 

^  Haemoglobin  98  per  cent.  ;  reds  normal  in  size,  some  irregularity  in  staining. 
Among  the  forms  classed  as  polymorphonuclear  neutrophiles  were  an  unusual 
number  whose  nuclei  were  but  partly  divided,  and  rarely  one  almost  a  myelocyte. 
No  typical  myelocytes. 

•'  Hsemoglobin  90  per  cent.  ;  reds  normal. 

*  Haemoglobin  100  per  cent. ;  some  variability  in  coloring  of  reds  ;  reds  other- 
wise normal. 

Am  Surg  8 


114       BLOOD    IN    ITS    RELATION    TO    SURGICAL    DIAGNOSIS. 

But  still  more  interesting  were  the  changes  revealed  by  the 
differential  count,  which  showed  a  very  marked,  absolute,  and 
relative  increase  in  the  polymorphonuclear  neutrophiles,  with  a 
corresponding  diminution  of  the  lymphocytes  and  an  entire 
absence  of  the  eosinophiles  in  three  cases  out  of  four,  while  in 
the  fourth  they  were  greatly  reduced.  In  one  case  atypical 
forms  of  leucocytes  not  to  be  observed  in  normal  blood  were 
present.  The  details  of  these  counts  are  shown  in  the  table  on 
preceding  page. 

To  capitulate  briefly  : 

1.  At  the  end  of  complete  anaesthesia  there  is  occasionally 
a  slight  increase  of  leucocytes,  but  seldom  a  marked  leuco- 
cytosis. 

2.  At  the  end  of  operation  there  is  a  considerable  leuco- 
cytosis  in  one-half  the  cases,  and  in  almost  all  cases  some 
increase  beyond  that  found  at  the  end  of  complete  anaesthesia. 

3.  Simple  uncomplicated  fractures  seldom  increase  the  leuco- 
cyte-count to  any  considerable  extent. 

4.  The  blood  after  operation  for  malignant  growths  is  not 
necessarily  much  impoverished,  and  regenerates,  in  favorable 
cases,  quite  normally. 

5.  A  variation  in  the  hourly  leucocyte-count  exists  in  other 
conditions  than  the  preperforative  stage  of  typhoid,  and  may 
occur  in  health. 

6.  Very  violent  physical  exertion  produces  in  the  blood  a 
condition  which  leaves  physiological  limits  and  approaches  or 
is  identical  with  that  found  in  disease. 

The  writers  desire  to  thank  the  staff  of  the  Massachusetts 
General  Hospital,  the  Boston  City  Hospital,  and  St.  Elizabeth's 
Hospital  for  permission  to  study  cases  under  their  care.  At  the 
Boston  City  Hospital  white  counts  were  made  by  Mr.  W.  H. 
McBain,  Mr.  D.  A.  Hefferman,  Dr.  J.  H.  Mullin,  and  Dr.  R.  C. 
Thompson ;  at  St.  ^Elizabeth's  Hospital,  by  Drs.  J.  J.  Sullivan 
and  T.  F.  Hanna.  Differential  counts  of  Marathon  runners,  by 
Dr.  R.  C.  Larrabee. 


THE    EXAMINATION    OF    THE    BLOOD    IN    RELA- 
TION   TO    SURGERY    OF    SCIENTIFIC    BUT 
OFTEN   OF   NO   PRACTICAL  VALUE, 
AND    MAY    MISGUIDE    THE 
SURGEON. 


By  JOHN  B.  DEAVER,  M.D., 

PHILADELPHIA. 


The  object  of  this  paper  is  not  to  decrythe  value  to  the  sur- 
geon of  examinations  of  the  blood,  for  we  undoubtedly  can  by 
this  means  often  obtain  valuable  information  as  to  the  nature 
and  progress  of  pathological  conditions  that  can  be  obtained  in 
no  other  way.  Yet  valuable  as  this  sign  is,  its  usefulness  is 
confined  to  quite  narrow  limits,  and  even  in  its  proper  field  its 
significance  is  frequently  very  difficult  and  sometimes  impos- 
sible to  determine. 

The  blood-count  is  a  valuable  physical  sign,  but  it  is,  how- 
ever, only  one  sign,  and  should  be  kept  in  its  proper  perspec- 
tive. One  spot  is  not  sufficient  evidence  upon  which  to  base  a 
diagnosis  of  typhoid  fever,  nor  can  the  presence  of  pus  be 
asserted  or  denied  from  an  estimation  of  the  number  of  leuco- 
cytes alone. 

In  the  last  few  years  there  has  crept  into  the  profession  a 
tendency  to  replace  the  bedside  by  the  laboratory  as  the  point 
from  which  to  make  the  diagnosis ;  to  substitute  the  highly 
magnified  but  extremely  limited  field  of  the  microscope  for  the 
broader  view  of  the  eye  of  the  physician.  This  we  regret,  for  in 
the  majority  of  instances  the  diagnosis  must  be  made  at  the  bed- 
side without  the  aid  of  the  microscopist,  and  any  man  who  has 
no  confidence  in  diagnoses  made  without  the  aid  of  the  labora- 
tory limits  his  usefulness. 


Il6  DEAVER, 

The  blood-count  theoretically  promises  the  surgeon  more 
perhaps  than  any  other  of  the  lines  of  laboratory  investiga- 
tion, and  is  certainly  of  great  practical  value,  yet  the  informa- 
tion thus  obtained  is  open  to  many  fallacies,  and  the  surgeon 
who  depends  on  this  means  alone  to  decide  for  or  against  opera- 
tion in  any  condition  is  often  acting  to  the  detriment  of  his 
patient. 

The  technique  of  a  blood-count  is  one  in  which  there  are 
opportunities  for  inaccuracies  without  number,  and  the  dilution 
with  which  it  must  be  made  multiplies  each  error  a  hundred- 
fold. Therefore,  except  in  the  hands  of  an  expert,  its  evidence 
is  always  open  to  a  reasonable  doubt,  and  even  with  an  expert 
it  is  only  on  repeated  examinations  that  absolute  dependence 
can  be  placed. 

The  secret  of  life-saving  surgery  is  promptness  in  diagnosis 
and  operation,  and  often  the  time  lost  in  awaiting  the  confirma- 
tion of  our  opinions  by  the  laboratory  can  be  ill  afforded  by 
the  patient. 

An  effort  has  been  made  lately  to  determine  the  exact  degree 
of  anaemia  below  which  it  is  unwise  to  attempt  a  surgical  opera- 
tion. In  this  we  are  asking  more  of  a  blood-count  than  it  will 
ever  be  able  to  give.  In  medicine  we  are  dealing  with  living 
organisms,  with  widely  varying  powers  of  resistance,  and  there- 
fore the  degree  of  anaemia  compatible  with  successful  surgery 
will  vary  with  each  patient.  Then,  too,  what  the  operation 
promises  is  another  important  factor;  for  we  are  certainly  justi- 
fied in  attempting  an  operation  which,  if  successful,  will  restore 
our  patient  to  health  under  conditions  that  would  positively 
forbid  a  merely  palliative  operation. 

To  illustrate  this,  let  me  briefly  cite  two  cases  that  have 
recently  occurred  in  my  practice. 

Case  I. — Mrs.  L.  B.,  aged  fifty-five  years,  was  admitted  to  the  Ger- 
man Hospital  December  20,  1900,  and  the  following  history  obtained  : 
Family  and  previous  histories  negative.  Menstruation  physiological 
until  three  years  ago,  when  she  apparently  reached  the  menopause  in 
a  perfectly  normal  manner.  After  an  interval  of  eight  months  an  exces- 
sive metrorrhagia  appeared,  accompanied  by  a  profuse  offensive  leucor- 


THE  BLOOD  IN  RELATION  TO  SURGERV.      11/ 

rhoea.  One  year  later  a  fibromyoma  was  expelled  from  the  uterus ; 
this  was  followed  by  a  temporary  improvement,  but  six  months  later 
the  symptoms  were  as  bad  as  ever,  and  she  has  steadily  and  rapidily 
lost  strength  and  weight  ever  since. 

On  admission  the  patient  is  extremely  emaciated,  with  that  bronz- 
ing of  the  skin  very  suggestive  of  malignant  disease,  and  so  weak  that 
she  is  hardly  able  to  raise  herself  in  bed.  She  has  a  very  offensive  leu- 
corrhcea  and  an  almost  constant  metrorrhagia.  A  large,  hard  mass  can 
easily  be  made  out  connected  with  the  uterus  and  rising  above  the 
symphysis  pubis. 

The  cervix  is  patulous,  and  presenting  at  the  internal  os  can  be  felt 
a  large  fibroid. 

On  the  day  after  admission  her  blood-count  was  haemoglobin,  27 
percent.;  erythrocytes,  4,070,000;  leucocytes,  5200.  She  was  put 
upon  appropriate  treatment,  but  showed  only  the  slightest  improve- 
ment. On  December  31,  1900,  the  blood-count  was  haemoglobin,  30 
per  cent.;  red  blood-cells,  3,980,000;  whites,  5400.  Despairing  of 
much  improvement  by  delay,  she  was  then  operated  upon.  A  large 
multinodular  uterine  fibroid  was  removed  by  an  abdominal  pan- 
hysterectomy and  the  wound  closed  without  drainage.  Conval- 
escence was  uneventful,  and  the  patient  left  the  hospital  February  11, 
1901,  in  good  health.  She  has  been  seen  within  the  last  two  weeks 
and  reports  herself  to  be  perfectly  well. 

Case  II. — Mrs.  M.  C,  aged  forty-eight  years,  was  admitted  to  the 
wards  of  the  German  Hospital  with  the  following  history :  A  brother 
died  of  cancer  of  the  stomach,  but  the  family  history  was  otherwise 
negative.  Previous  personal  history  negative ;  menstruation  always 
physiological.  No  metrorrhagia  or  excessive  menorrhagia.  For  the 
last  six  years  has  been  conscious  of  a  mass  in  the  lower  abdomen,  and 
during  this  time  has  lost  about  forty  pounds  in  weight.  For  the  last 
two  years  has  been  extremely  weak  and  short  of  breath. 

Examination  on  admission  shows  the  patient  to  be  a  tall,  thin 
woman,  with  all  the  inspection  symptoms  of  carcinoma.  A  soft, 
blowing  murmur  is  heard  at  the  base  of  the  heart.  The  blood-count 
on  the  day  of  admission  was  haemoglobin,  22  per  cent.;  erythrocytes, 
2,980,000;  leucocytes,  5200.  A  large  mass  could  be  felt  in  the  lower 
abdomen,  both  by  vaginal  and  supervaginal  palpation. 

She  was  operated  on  the  next  day  and  a  large  fibromyoma  removed 
by  an  abdominal  pan-hysterectomy  ;  wound  closed  without  drainage. 


Il8  DEAVER, 

Convalescence  was  uneventful,  and  the  patient  left  the  hospital   Feb- 
ruary 2,  1900,  in  very  good  condition. 

Grave  anaemias  are,  of  course,  a  general  contraindication  to 
an  anaesthetic  and  operation  in  the  same  way  that  organic 
heart  lesions  and  nephrites  are,  yet  we  all  know  how  often  the 
severest  operations  are  successfully  performed  in  the  presence 
of  these  complications. 

Sometimes  in  a  patient  suffering  from  prolonged  suppuration, 
frequent  hemorrhage  or  other  conditions  that  would  lead  us  to 
expect  a  profound  anaemia,  we  find  either  a  normal  or  abnor- 
mally high  percentage  of  haemoglobin  and  erythrocytes.  Such 
results  are  very  often  misleading,  as  they  by  no  means  express  the 
blood  condition  of  the  patient.  The  chief  cause  leading  to  this 
artefact  is  a  transient  concentration  of  the  blood  due  to  a  les- 
sening of  its  fluid  constituents  from  purgation,  excessive  vomit- 
ing, or  free  sweating.  In  addition  to  this,  a  stasis  in  the  periph- 
eral circulation  from  either  organic  heart  disease  or  functional 
depression  from  profound  tox^iemia  will  raise  the  blood-count 
above  the  true  measure  of  the  patient's  anaemia. 

The  significance  of  the  presence  or  absence  of  a  leucocytosis 
is  perhaps  the  part  of  this  subject  with  which  we  as  surgeons 
are  most  often  concerned. 

Without  going  into  the  discussions  that  have  recently  arisen 
on  this  subject,  we  can  consider  the  phenomena  of  leucocytosis 
as  primarily  one  of  phagocytosis,  it  making  no  difference 
whether  the  toxic  materials  are  directly  taken  up  by  the 
leucocytes  or  neutralized  by  a  substance  formed  in  part  by 
their  activity. 

If  poisons  of  certain  kinds  are  in  the  general  circulation 
there  is  ordinarily  a  general  leucocytosis,  its  grade  depending 
largely  on  the  resisting  powers  of  the  individual  and  the  amount 
and  kind  of  poison. 

Sometimes  a  sudden  and  overwhelming  dose  of  septic  poison 
will  so  depress  the  patient  that  there  is  no  phagocytic  reaction 
and  a  leucocytosis  does  not  appear.  Then,  too,  in  prolonged 
suppurative  processes,  with  free  absorption  of  the  septic  poison 


THE  BLOOD  IN  RELATION  TO  SURGERY.      II9 

at  first,  there  is  an  active  phagocytosis  with  a  large  leucocytosis, 
but  as  the  powers  of  resistance  of  the  patient  sink  the  leucocytosis 
becomes  very  insignificant ;  or,  as  time  goes  on,  the  focus  of  sup- 
puration maybe  shut  off  by  nature  from  the  general  circulation, 
and  again  the  number  of  leucocytes  fall. 

In  a  general  way  high  grades  of  leucocytosis  are  most  com- 
monly satisfactory  signs  ;  while  they  are  due  to  severe  infection 
they  usually  mean  good  reaction.  Moderate  grades  of  leuco- 
cytosis, if  the  other  signs  of  infection  are  severe,  are  in  them- 
selves suggestive  of  a  bad  result ;  if  the  other  signs  of  infection 
are  slight  a  mild  leucocytosis  means  nothing  of  itself 

If  the  origin  of  the  infection  is  in  a  part  of  the  body  rich  in 
lymphatics  and  rapid  in  absorption,  other  things  being  equal, 
the  leucocytosis  will  be  more  marked.  Thus  it  is  that  a  peri- 
tonitis gives  a  greater  leucocytosis  than  a- pleurisy  and  why  the 
upper  part  of  the  peritoneal  cavity  if  infected  gives  a  quicker 
and  more  profound  systemic  infection  than  the  lower. 

Of  course,  in  a  streptococcus  infection,  per  se,  we  would  get 
a  higher  grade  of  leucocytosis  than  in  a  staphylococcus  ;  yet,  as 
we  have  shown,  the  degree  of  leucocytosis  is  so  dependent  on 
the  amount  of  poison  absorbed  and  the  resistance  of  the 
patient  that  we  can  form  no  judgment  as  to  the  character  of 
the  infection  from  the  blood-count. 

For  years  the  text-books  have  nearly  all  contained  the  state- 
ment that  there  is  commonly  a  leucocytosis  in  cancer.  On 
what  this  is  founded  we  do  not  know,  for  anyone  with  any 
practical  experience  in  this  matter  must  know  that  such  is  not 
the  case,  a  leucocytosis  in  this  condition  being  very  uncommon, 
and  does  not  seem  to  be  influenced  by  metastasis.  Only  nine- 
teen out  of  forty-nine  patients  at  the  German  Hospital  suffer- 
ing from  carcinoma  gave  a  leucocyte-count  of  over  10,000,  and 
only  two  of  these  were  above  20,000,  these  two  being  respec- 
tively an  ulcerating  carcinoma  of  the  breast,  which  gave  a 
blood-count  of  31,500  leucocytes,  and  a  carcinoma  of  the  liver, 
with  40,800  leucocytes. 

In  cases  of  appendicitis  we  cannot  depend  on  the  blood-count 
for  our  indication  for  operation,  for  the  favorable  time   for  this 


I20  DEAVER, 

operation  is  in  the  first  hours  of  the  attack,  when  the  chief 
symptoms  are  those  of  appendicial  colic,  and  before  severe 
systemic  infection  has  taken  place.  In  these  cases  we  often 
have  rupture  of  the  appendix  or  transmigration  of  organ- 
isms so  suddenly  infecting,  in  an  overwhelming  manner,  the 
entire  peritoneal  cavity  that  a  leucocytosis  is  not  established,  or 
is  very  evanescent,  owing  to  the  rapid  paralysis  of  the  resisting 
powers  of  the  individual.  Or,  as  the  symptoms  improve  and 
the  leucocytosis  falls,  we  might  think  that  the  appendix  was 
becoming  normal  again,  when  the  truth  was  that  an  abscess  had 
only  become  localized  and  no  more  septic  material  was  being 
absorbed.  If,  acting  on  this  supposition,  we  should  decline  to 
operate  we  would  leave  our  patient  exposed  to  the  greatest  risk 
of  a  secondary  outbreak  that  would  be  very  likely  to  cost  him 
his  life. 

We  will  be  doing  much  better  surgery  if  we  promptly  operate 
on  our  appendicitis  cases  than  if  we  waste  time  over  a  blood- 
count  that,  as  is  shown  by  Dr.  Da  Costa's  paper,  read  before 
you,  is  of  very  little  value. 

In  the  experience  of  the  author  in  cases  of  salpingitis,  even 
quite  moderate  grades  of  leucocytosis  (14,000  to  17,000)  are  in- 
dicative of  the  presence  of  pus.  Yet  this  is  by  no  means  con- 
stant, for  nature  is  so  well  able  to  care  for  these  cases  that 
often  large  collections  of  pus  are  present  without  a  leucocy- 
tosis, much  to  the  embarrassment  of  the  surgeon  who  depends 
upon  the  blood-count  alone  to  show  the  presence  of  suppura- 
tion. 

In  cases  of  obstructive  jaundice  a  leucocytosis  is  usually  but 
not  always  present,  and  in  our  experience  seems  to  be  most 
often  due  to  a  local  peritonitis  around  the  gall-bladder.  In  8 
out  of  14  cases  of  obstructive  jaundice  due  to  gallstones  a  leu- 
cocytosis was  present. 

Although  I  have  not  the  data  at  hand  to  verify  this  statement, 
I  will  venture  the  opinion  that  the  most  virulent  of  micro- 
organisms may  inhabit  the  altered  bile  of  an  occluded  gall- 
bladder without  giving  systemic  signs,  thus  explaining  many 
cases    of  peritonitis    after    gallstone    operations,  in   which  the 


THE  BLOOD  IN  RELATION  TO  SURGERY.      121 

operator,  thinking  the  bile  sterile,  has  allowed  it  to  soil  the  gen- 
eral abdominal  cavity. 

Pohl/  Wilkinson,-  and  Boland'^  have  done  some  very  interest- 
ing work  in  regard  to  drug  leucocytosis.  These  investigators 
have  found  that  many  drugs  have  the  power  of  producing  a  quite 
marked  leucocytosis  ;  among  these  quinine,  the  salicylates,  anti- 
pyrine,  phenacetin,  pilocarpine,  Dover's  powder,  and  morphine; 
all  drugs  that  our  patients  may  have  been  taking  at  the  time 
we  are  called  upon  to  make  a  diagnosis. 

We  might  go  on  showing  many  other  instances  of  surgical 
conditions  in  which  the  blood-count  is  of  doubtful  value,  or  at 
any  rate  disappointing;  but  we  have,  we  think,  said  enough  to 
define  our  position. 

We  believe  that  if  we  have  a  decided  leucocytosis  (20,000  or 
over)  after  excluding  pneumonia,  leukaemia,  etc.,  we  can  safely 
infer  the  presence  of  pus.  Yet  without  a  leucocytosis  we  can- 
not be  sure  that  pus  does  not  exist.  We  also  consider  ex- 
quisite tenderness,  temperature,  pulse,  and  the  general  appear- 
ance of  the  patient  as  much  more  reliable  guides  than  the  blood- 
count. 

Therefore,  gentlemen,  we  wish  to  say,  in  conclusion  :  let  us 
have  blood-counts  made  on  our  patients.  We  have  already 
learned  valuable  lessons  from  them,  and  undoubtedly  will  learn 
more  in  the  future ;  but  let  us  not  be  drawn  aside  by  their  still 
uncertain  evidence  from  the  lessons  learned  by  practical  expe- 
rience at  the  bedside. 

In  the  preparation  of  this  communication  I  wish  to  credit 
Dr.  Edward  Kemp  Moore,  my  ex-house  surgeon,  for  the 
greater  part  of  the  work  thereon. 

•  Archiv  fiir  exper.  Path,  und  Pharmak.,  vol.  xv.,  1889. 

2  British  Medical  Journal,  September  26,  1896. 

3  Centralblatt  fiir  innere  Medicin,  April  5,  1900. 


BLOOD   EXAMINATIONS  AS  AN  AID  TO  SURGICAL 

DIAGNOSIS. 


By  JOSEPH   C.  BLOODGOOD,  M.D., 

BALTIMORE,  MD. 


Shock  and  Hemorrhage.  Observations  have  demonstrated  that 
there  is  a  leucocytosis  of  15,000  to  24,000  following  hemor- 
rhage. As  a  rule,  this  comes  on  within  a  few  hours.  There  are 
not  sufficient  observations  to  demonstrate  the  relation  between 
the  amount  of  blood  lost  and  the  leucocyte-count.  We  have  not 
sufficient  data  to  clearly  determine  the  exact  changes  in  the 
number  of  white  blood-cells  in  shock  from  injury  alone  with- 
out loss  of  blood. 

Following  hemorrhage,  in  addition  to  the  rise  in  the  number 
of  leucocytes,  there  is  a  diminution  in  the  number  of  red  blood- 
cells  and  the  percentage  of  haemoglobin.  In  severe  hemorrhage 
a  blood-count  will  indicate  to  a  certain  extent  the  amount  of 
blood  lost,  but  as  a  rule  not  until  six  or  more  hours  have  inter- 
vened after  hemorrhage. 

The  examinations  of  the  blood  after  contusion  of  the  abdo- 
men, to  ascertain,  if  possible,  whether  we  can  distinguish  by  the 
changes  in  the  elements  of  the  blood  the  difference  between 
shock  from  the  injury  alone,  internal  hemorrhages,  and  perito- 
nitis from  rupture,  are  not  sufficient  in  number  to  allow  any  con- 
clusions. 

Cabot' writes :  "Often  one  hears  the  question  discussed  in 
any  accident-room  in  any  hospital  whether  to  operate  at  once 
or  wait  until  the  patient  has  got  over  the  shock.     The  question 

'  Clinical  Examination  ot  the  Blood,  William  Wood  &  Co.,  New  York,  1898,  and 
International  Text-book  of  Surgery,  Warren  and  Gould,  1900,  vol.  i.  p.  81. 


BLOOD     EXAMINATIONS    AND    SURGICAL     DIAGNOSIS.        I23 

is  not  often  asked,  far  less  answered,  whether  the  shock  is  simple 
or  largely  anaemic  (cerebral  or  general)  from  loss  of  blood,  or 
whether  it  is  of  nervous  origin — /.  e.,  due  to  concussion  or  com- 
pression. The  right  decision  of  this  question  is  of  great  im- 
portance, for  if  the  shock  means  anaemia,  transfusion  may  be 
indicated,  while  in  a  condition  of  cerebral  concussion  or  com- 
pression, transfusion  will  probably  do  harm."  (Authorities  do 
not  agree  with  Cabot.  Transfusion  is  not  contraindicated.') 
"An  examination  of  the  blood  enables  us  in  certain  cases  to 
decide  such  a  question — that  is,  if  the  number  of  red  cells  is 
considerably  diminished  (3,500,000  or  less)  and  the  patient  is 
known  not  to  have  been  previously  anaemic,  the  shock  probably 
means  hemorrhage."  "  The  blood-count  may  enable  us  to 
gauge  approximately  the  amount  of  hemorrhage.  Here  it 
should  be  remembered,  however,  that  immediately  after  hem- 
orrhage the  count  may  be  normal,  since  only  the  amount  and 
not  the  quality  of  the  blood  is  affected.  Within  a  few  hours, 
however,  fluid  is  absorbed  from  the  tissues  into  the  vessels,  and 
then  an  an^Emia  will  be  indicated  by  the  blood-count."  "An 
internal  or  cerebral  hemorrhage,  a  rupture  of  an  extra-uterine 
pregnancy,  ruptured  aneurism,  laceration  of  the  spleen,  kidney, 
or  liver,  etc.,  can  sometimes  be  diagnosed  by  the  blood  exam- 
ination." 

McLean,"  in  his  article  entitled  "  Examination  of  the  Blood 
in  Surgical  Diseases,"  practically  adds  nothing  new  to  Cabot's 
statement  in  regard  to  the  blood  examination  in  shock. 

The  Importance  of  a  Careful  Blood  Examination  Preliminary 
to  General  Anesthesia.  There  are  now  sufficient  observations  to 
demonstrate  pretty  conclusively  that  in  marked  anaemia,  espe- 
cially when  the  haemoglobin  percentage  is  low,  that  general 
anaesthesia,  especially  if  prolonged,  is  dangerous.  Some  author- 
ities give  50  per  cent.,  others  40  per  cent. ;  but  the  majority 
agree  that  30  per  cent,  of  haemoglobin  is  a  danger  signal,  and  if 
possible  the  operation  should  be  delayed  until  appropriate  treat- 


'   Progressive  Medicine,  December,  1900,  p.  108. 
2  Medical  News,  December,  1899,  vol.  Ixxv.  p.  713. 


124  BLOODGOOD, 

merit  has  been  used  to  increase  the  percentage  of  haemoglobin 
and  the  number  of  red  blood-cells. 

This  important  subject  has  been  studied  by  Cabot/  Da  Costa, 
Mikulicz,  Hamilton  Fish,"  and  others. 

My  own  experience  has  been  sufficient  to  indicate  the  truth 
of  their  statements.  An  anaesthetic  has  great  additional  dangers 
when  given  to  patients  with  the  haemoglobin  estimate  below  50 
per  cent. 

Post-operative  Leucocytosis.  There  is  need  for  much  more 
study  on  this  question.  Most  authorities  agree  that  following 
ether  there  \s  perhaps  a  slight  increase  in  the  leucocytes,  which, 
however,  disappears  within  twenty-four  and  at  most  thirty-six 
hours.  In  operations  with  much  loss  of  blood  there  would,  of 
course,  be  a  temporary  rise  in  the  leucocytes  ;  but,  on  the  whole, 
in  the  average  operation  one  should  expect  the  leucocytes  to  be 
within  the  normal  limits — twenty-four  hours  after  operation.  If 
this  is  true,  a  sudden  rise  in  the  leucocytes  would  indicate  some 
post-operative  complication.  In  abdominal  surgery  it  would 
suggest  peritonitis,  although  if  the  peritonitis  was  a  very  grave 
infection  the  leucocytes  would  soon  fall  rapidly.  Perhaps  the 
leucocyte  count  as  an  aid  to  the  post-operative  diagnosis  in 
abdominal  surgery  is  most  certain  in  the  early  recognition  of 
obstruction.  Here  there  is  always  a  rise,  usually  over  20,000, 
associated  with  any  obstruction  of  the  intestines.  This  rise 
generally  takes  place  within  from  eight  to  twenty  hours  after 
the  beginning  of  the  obstruction,  and  in  a  few  cases  observed 
the  rise  in  the  leucocytes  had  been  prominent  before  the  clinical 
symptoms  themselves  were  sufficiently  clear  to  make  a  positive 
diagnosis.  The  number  of  observations  so  far  have  demon- 
strated that  when,  after  laparotomy  with  general  anaesthesia, 
the  patient  develops  slight  distention,  or  even  marked  disten- 
tion, with  nausea  and  vomiting,  which  seems  more  or  less  due 
to  paralysis  of  the  intestines,  and  not  to  a  definite  obstruction 
or  peritonitis,  the  leucocytes  do  not  rise,  at  least  not  above  12,000 
to  15,000.     If  these  observations  are  confirmed,  the  counting  of 

'  Loc.  cit.  "^  Annals  of  Surgery,  1899,  vol.  xxx.  p.  79. 


BLOOD     EXAMINATIONS    AND    SURGICAL     DIAGNOSIS.       12$ 

the  white  blood-cells  would  be  a  great  aid  in  the  differential 
diagnosis  in  the  first  twenty-four  to  forty-eight  hours  or  later, 
after  laparotomy,  between  benign  abdominal  distention  and  ob- 
struction or  peritonitis,  for  which  operative  interference  would 
be  indicated  early.  This  is  apparently  a  closer  relation  between 
the  extent  and  character  of  the  operation  and  the  post-operative 
leucocyte  count  than  the  anaesthetic.  A  more  complete  report 
on  this  is  in  preparation,  and  will  be  published  later. 

Post- operative  Phlebitis.  In  a  few  cases  observed  there  is  a  rise 
in  the  leucocytes,  varying  from  15,000  to  20,000.  Such  a  leu- 
cocytosis  has  been  observed  frequently  in  typhoid  phlebitis  ;  but, 
on  the  whole,  the  observations  of  the  changes  in  the  leucocytes 
after  operation  are  not  well  established. 

If  the  phlebitis  is  confined  to  the  iliac  veins  the  first  symp- 
toms are  those  of  an  acute  abdominal  lesion,  viz.,  localized  pain 
and  slight  muscle  spasm  in  the  iliac  fossa ;  nausea  and  vomit- 
ing. If  on  the  right  side,  after  operation,  the  condition  might 
simulate  an  appendicitis,  or,  in  women,  a  salpingitis.  In  typhoid 
fever  the  early  clinical  picture  is  very  much  like  intestinal  per- 
foration. A  case  of  this  character  has  been  reported  by  Harvey 
Gushing;'  also  by  William  S.  Thayer,^  in  his  article  entitled 
"  Observations  of  Blood  in  Typhoid  Fever." 

The  Importance  of  the  Leucocyte-count  in  the  Early  Recognition  of 
Acute  Abdominal  Lesions.  The  discussion  of  this  subject  is  the 
chief  theme  of  this  paper,  not  only  because  of  its  importance, 
but,  fortunately,  in  this  field  we  have  more  observations. 

Explanation  of  Table.  The  following  table  represents  all  the  counts 
made  on  cases  of  appendicitis.  The  first  count  in  practically  every  in- 
stance was  made  when  the  patient  was  first  admitted  to  the  hospital,  and 
this  count  is  placed  under  the  time  corresponding  to  the  number  of  hours 
or  days  since  the  beginning  of  the  acute  attack  ;  subsequent  counts  (if 
made)  are  noted  by  dotted  lines  after  the  first  count  under  the  proper 
time.  In  the  cases  operated  upon  the  last  count  represents  the  time  of 
the  operation,  with  one  exception,  in  the  group  appendicitis,  general 

1  Johns  Hopkins  Hospital  Bulletin,  No.  92,  November,  1898. 
*  Johns  Hopkins  Hospital  Reports,  vol.  viii.,  1900. 


126 


BLOODGOOD, 


peritonitis,  operation.  The  letters  Op.  under  the  figure  20  represents 
the  time  of  operation.  The  three  subsequent  counts  are  post-opera- 
tive, and  show  the  fall  in  the  leucocytes,  with  general  peritonitis. 
Under  the  column  appendicitis,  abscess,  operation,  there  are  only  single 
counts. 


Hours. 

Days. 

Weeks. 

Month 

! 

II. 

III. 

IV. 

V. 

VT. 

6  to  14    16 

20 

24     30 

36 

40 

48 

to 
III. 

to 
IV. 

to 
V. 

to 
VI. 

to 
VII. 

lto2 

2to4 

1 

Chronic  and  subacute  appiendicitis. 


75 


10 
.10.. 
75 


5 
6 
12 
12 


Acute  appendicitis.    Xo  operation.    Recovery. 


i  7^  -12 

77-1 , -13- 

\22  i -16- 


17. 
11 


9 


...7...  I  ...6 


172-8  1 


8-n- 

17 


Acute  diffuse  appendicitis.    Operation.    Recovery. 
I   77 9 


12 
13 


18 
13 
17 
25 


Gangrenous  appendicitis.    Operation.    Recovery. 


17 
73__16--24--7  7- 
13     '23     25 


2/ 

74-1-20-17 


13 


r  I 


Acute  appendicitis  distended  with  pus.    Operation.    Recovery. 


15 
19 


7  7-20 
27-28 


78-24    -35       (5  hours) 


Appendicit 

is.    Abscess.    Operation. 

11  1 

1 

11        11 

12 

12     i     11 

8 

(-)  6 

18  1 

19 

20 

16 

24         12 

14 

7 

! 

22 

26 

16 

26     ,     14 

(2)17 

8 

1 

27 

30 

29      (2)15 
(•^)18 

(2)19 

25 

27 

,     30 

(=-')18 
19 
25 
60 

(-')12 

(2)15 
(2)18 

19 
29 

(2)28 

Appendicitis.    General  peritonitis.    Operation. 


14 

32 

36 

25 

R 

R 

R 

D 

8- 

20 
Op. 

23 

26 

11 
D 

11 

D 

n 

D 

13 
D 
14 
D 
17 
R 


21 
D 
24 
D 

25 
D 
40 
D 


(2)  9 

(3)11 

14 
16 
18 
19 


BLOOD     EXAMINATIONS     AND    SURGICAL     DIAGNOSIS.       12/ 

The  figure  2  or  3  in  front  of  the  figures,  representing  the  number 
of  leucocytes,  indicates  that  there  were  two  or  three  cases  with  this 
number  of  leucocytes  at  this  time.  Under  the  column  appendicitis, 
general  peritonitis,  operation,  the  letter  R  indicates  the  patient  recov- 
ered, and  D  the  patient  dead.  The  time  in  these  cases  represents  the 
entire  interval  of  the  acute  attack,  and  not  the  duration  of  the  peri- 
tonitis, which,  in  the  majority  of  cases,  was  impossible  to  ascertain. 

Leucocytosis  in  Appendicitis.  When  observed  within  forty- 
eight  hours  the  number  of  white  blood-cells  is  in  a  majority  of 
instances  of  great  value,  indicating  the  extent  of  the  inflamma- 
tory condition  of  and  about  the  appendix.  This  fact  is  well 
illustrated  in  the  table. 

Chronic  and  Subacute  Appendicitis.  Sixteen  counts.  Here 
we  have  cases  of  recurrent  appendicitis,  or  of  appendicitis  suf- 
fering from  the  first  attack ;  first  observed  practically  at  the  end 
of  the  attack,  when  the  clinical  symptoms  were  subsiding  or 
practically  over.  The  almost  uniform  low  leucocyte-count, 
even  in  this  small  group  of  cases,  is  very  suggestive  that  such 
an  observation  is  an  important  additional  aid  to  recognize  that 
an  acute  attack  of  appendicitis  is  subsiding;  or  when  seen  later, 
after  the  clinical  signs  have  entirely  disappeared,  the  absence  of 
leucocytosis  should  be  considered  a  distinct  factor  in  excluding 
an  abscess.  It  is  noticed  in  the  table  that  the  highest  count  in 
this  group  of  cases  was  15,000.  In  i  admitted  thirty-six  hours 
after  the  beginning  of  the  attack,  and  in  which  the  local  clinical 
symptoms  were  distinctly  less  according  to  the  statement  of  the 
patient,  and  which  when  admitted  were  just  sufficient  to  suggest 
an  appendicitis,  observed — these  slight  local  symptoms  disap- 
peared, associated  with  a  fall  in  the  leucocytes  to  10,000  and 
6000.  A  later  operation  demonstrated  a  diffuse  thickened 
appendix,  but  no  pus.  Observed  between  the  second  and 
seventh  day,  the  leucocyte-counts  have  been  15,000  in  2  cases, 
10,000  in  2  cases,  in  i  falling  to  7000,  and  in  i  case  11,000. 
With  b2it  a  few  exceptions  these  are  distinctly  lower  counts  than 
in  the  other  groups  of  cases.  In  all  of  these  cases,  at  an 
operation  performed  later,  a  simple  diffuse  appendicitis  was  found 
with  no  pus  or  evidence  of  infection  outside  of  the  appendix.   In 


128  BLOODGOOD, 

10  cases  observed  from  one  week  to  one  month  after  the  last 
acute  attack,  in  only  2  cases  were  the  leucocytes  as  high  as 
12,000,  the  remainder  were  9000  and  lower.  In  the  majority  of 
these  cases  there  were  no  clinical  symptoms,  simply  a  history 
of  one  or  more  previous  attacks.  At  the  operation  a  diffuse 
appendicitis  was  found,  with  no  evidence  of  pus  outside  of  the 
appendix. 

Comparing  this  group  with  cases  of  appendicular  abscess  ad- 
mitted from  one  week  to  one  month  after  the  beginning  of  the 
attack  (33  cases)  we  see  distinct  differences.  In  those  cases  with 
abscess,  only  6  out  of  the  33  cases  had  leucocyte-counts  below 
12,000.  Some  of  these  33  cases  of  abscess  exhibited  no  clinical 
evidence  of  tumor.  This  observation  demonstrates  that  in  cases 
of  appendicitis  admitted  late  in  the  attack  a  high  leucocyte-count 
is  almost  a  positive  evidence  of  an  abscess,  even  when  the  clini- 
cal symptoms  have  entirely  subsided  and  the  abdominal  exami- 
nation is  negative.  In  a  few  cases,  but  only  a  few,  we  may  ex- 
pect to  find  a  small  localized  abscess  even  when  white  blood- 
cells  show  no  marked  increase ;  but  this  is  a  rare  exception  to 
the  general  rule. 

Future  observations  may  demonstrate  that  the  leucocyte- 
count  will  aid  us  in  indicating  the  better  time  to  operate  in  cases 
of  appendicitis  with  abscess.  Many  of  these  patients  come  to 
the  hospital  at  the  end  of  the  attack,  the  clinical  symptoms  are 
subsiding  or  have  ceased,  and  we  usually  find  on  abdominal 
palpation  an  area  of  tumor  or  induration,  suggesting  a  localized 
collection  of  pus,  which  in  some  instances,  however,  proves  to 
be  a  mass  of  adherent  omentum.  Now  and  then  in  such  cases 
when  we  have  delayed  we  have  found  that  the  localized  pus  has 
become  much  inspissated  and  the  virulence  of  the  organism  may 
have  decreased.  Experience  would  seem  to  demonstrate  that 
if  the  pus  is  distinctly  localized  and  the  symptoms  on  the  de- 
crease, it  is,  perhaps,  the  safer  plan  to  delay  the  operation  to  a 
date  when  the  difificulty  of  removing  the  appendix  and  the 
danger  of  infecting  the  general  peritoneal  cavity  would  be 
less.  Our  cases  require  a  more  minute  study  before  such  a 
conclusion  can  be  demonstrated. 


BLOOD     EXAMINATIONS    AND    SURGICAL     DIAGNOSIS.       1 29 

Acute  Appendicitis.  No  Opemtion.  Recovery.  In  the  cases 
admitted  within  forty-eight  hours  with  acute  symptoms,  if  on 
on  account  of  the  clinical  picture  operation  has  been  delayed, 
we  have  always  observed  a  falling  leucocytosis.  These  patients 
have  recovered,  and  at  a  later  operation  the  appendix  is  found  to 
be  the  seat  of  a  diffuse  inflammation,  but  there  has  been  no 
evidence  of  pus  outside  the  appendix.  In  i  case  admitted  six- 
teen hours  after  the  beginning  of  the  attack  the  leucocytes  fell 
in  ten  hours  from  17,000  to  13,000,  and  in  twenty-four  hours  to 
1 1,000,  associated  with  the  disappearance  of  the  symptoms.  With 
one  exception  the  highest  first  leucocyte-count  in  this  group 
has  been  17,000,  falling  in  a  few  hours  to  12,000,  9000  or  even 
lower.  A  patient  admitted  twenty  hours  after  the  beginning  of 
the  acute  attack  had  a  leucocytosis  of  22,000.  The  clinical 
symptoms,  however,  were  not  very  marked.  The  patient  was 
observed  eight  hours  ;  during  this  period  the  leucocytes  fell  to 
16,000,  and  the  local  symptoms  practically  disappeared.  Within 
the  next  twenty-four  hours  the  leucocytes  were  11,000,  then 
8000,  7000,  then  6000.  Athough  this  patient  with  a  leucocy- 
tosis of  22,000  at  the  end  of  twenty  hours  recovered,  and  there 
is  every  reason  to  believe  that  the  inflammatory  condition  about 
the  appendix  subsided,  nevertheless  it  is  an  exception  to  the 
general  rule,  and  it  would  be  safer,  I  believe,  to  operate  in  those 
cases  of  acute  appendicitis  observed  within  the  first  forty-eight 
hours  with  a  leucocytosis  of  20,000. 

Acute  Diffuse  Appendicitis.  Operation.  Recovery.  Eleven  cases. 
The  leucocyte  counts  in  this  group  of  cases  do  not  differ  much 
from  those  in  the  group  of  acute  appendicitis  which  were  not 
operated  on  until  after  the  end  of  the  acute  attack;  and  of  course 
it  is  a  question  whether  all  of  these  cases  might  have  recovered 
from  this  attack  without  operation.  It  is  to  be  noted  that  in 
one  case  observed  in  the  hospital  the  leucocytes  rose  from  8000 
to  18,000;  and  a  second  from  13,000  to  17,000.  In  three  cases 
there  was  a  fall  in  the  leucocytes  from  10,000  to  7000 ;  from 
11,000  to  9000,  and  from  14,000  to  10,000.  In  two  cases  ob- 
served at  the  end  of  two  days  and  five  days  it  was  a  question 
whether  the  patient  was  getting  over  the  attack  or  not,  but  it 

Am  Surg  9 


130  BLOODGOOD, 

was  considered  wiser  to  operate.  A  simple  diffuse  appendix 
was  found.  In  the  third,  admitted  twenty  hours  after  the  be- 
ginning of  the  attack  and  observed  four  hours,  the  patient 
clinically  was  distinctly  getting  worse,  the  leucocytes  had  fallen 
from  10.000  to  7000.  The  only  high  leucocyte-count  in  this 
group  of  cases  was  25,000.  This  patient  was  seen  thirty-six 
hours  after  the  beginning  of  the  attack,  and  clinically  the 
attack  seemed  to  be  subsiding ;  but  on  account  of  the  high 
leucocytosis  it  was  considered  best  to  operate.  In  this  case  the 
exudate  about  the  thickened  appendix  was  very  excessive,  and 
it  is  a  question  whether,  if  operation  had  been  delayed,  an 
abscess  would  not  have  developed. 

The  following  two  cases  are  reported  in  detail,  the  first  be- 
cause the  patient  was  observed  in  the  hospital  from  the  begin- 
ning, and  represents  the  typical  rise  in  the  leucocytes  from  8000 
to  18,000  in  thirty-six  hours,  associated  with  an  acute  diffuse 
appendicitis.  It  cannot  be  stated  in  this  case  whether  the 
patient  would  not  have  recovered  from  this  attack,  but  the  rise 
in  the  leucocytes  was  a  distinct  aid  in  the  early  recognition  of 
the  disease,  which  was  associated  with  but  slight  local  symp- 
toms. 

The  second  case  is  reported  in  detail  because  it  represents  the 
rare  exception  of  a  low  and  falling  leucocytosis  associated  with 
a  distinct  increase  in  the  local  symptoms,  in  which  case  the 
operation  was  indicated  chiefly  on  account  of  the  increasing 
local  signs,  although  a  careful  observation  indicated  a  falling 
and  a  low  leucocytosis. 

Case  I. — The  patient,  a  girl,  aged  seven  years,  was  admitted  to  the 
hospital  with  a  rather  indefinite  history  of  previous  attacks  of  pain  and 
the  history  of  pin-worms  in  the  stools.  When  first  admitted  and  ob- 
served for  seven  days  there  were  no  symptoms.  Suddenly,  one  night> 
she  began  to  complain  of  abdominal  colic,  which,  in  a  few  hours, 
localized  itself  in  the  right  iliac  fossa  ;  in  six  hours  the  leucocytes  were 
8000;  ten  hours,  11,000;  twenty-four  hours,  17,000;  thirty-six  hours, 
18,000.  During  this  time  the  temperature  rose  from  98°  to  100°  ;  no 
nausea  or  vomiting.  The  local  symptoms  consisted  only  of  but  slight 
muscle  spasm  and  tenderness  in  the  right  iliac  fossa.     The  slight  local 


BLOOD     EXAMINATIONS    AND    SURGICAL    DIAGNOSIS.       I3I 

abdominal  symptoms,  combined  with  the  quite  high  leucocytosis,  were 
considered  sufficient  to  indicate  an  early  operation.  The  appendix 
was  free,  but  thickened  by  diffuse  inflimmation  ;  the  lumen  of  the 
appendix  was  filled  with  small  pin-worms. 

Case  II. — A  colored  man,  aged  about  twenty  years,  entered  the 
hospital  with  a  history  of  diarrhoea  and  colic  of  one  week's  duration,  and 
of  local  symptoms  ;  pain  in  the  right  iliac  fossa,  suggesting  appendicitis 
of  twenty-four  hours'  duration.  The  first  examination,  temperature 
104.2°;  pulse,  99;  respiration,  30.  The  patient's  expression  was  one 
of  stupor;  tongue  coated,  but  moist;  leucocytes,  10,000.  The  abdom- 
inal symptoms  were  so  slight  that  the  possibility  of  typhoid  fever  was 
considered,  and  a  Widal  test  made,  which  was  suggestive  but  not  posi- 
tive. I  saw  the  patient  four  hours  later.  At  this  time  leucocytes  had 
fallen  to  7000,  and  the  temperature  to  102°;  but  on  examination  the 
tenderness  and  muscle  spasm  in  the  right  iliac. fossa  had  slightly  in- 
creased, and  there  was  a  distinct  area  of  dulness  in  the  right  flank, 
which  suggested  encapsulated  fluid.  At  the  operation  a  diffusely 
thickened  and  inflamed  appendix  was  found  covered  with  a  little  fresh 
exudate,  and  there  was  some  free  cloudy  sterile  fluid  in  the  abdominal 
cavity.  The  chief  collection  was  retrocsecal  where  the  appendix  was 
situated.  After  the  operation  the  patient  continued  to  have  intermit- 
tent fever  for  a  week,  the  cause  of  which  we  could  not  make  out ;  there 
were  no  malarial  organisms;  the  Widal  reaction  was  not  positive,  and 
there  was  no  leucocytosis.     He  made  an  uninterrupted  recovery. 

Gangrenous  Appendicitis.  Operation.  Recovery.  In  this  group 
of  cases,  as  a  rule,  the  leucocytosis  is  higher  and  rises  more 
rapidly,  and  in  three  instances  it  has  been  of  the  greatest  im- 
portance in  the  early  recognition  of  a  grave  inflammatory  con- 
dition of  the  appendix,  which  without  doubt  would  have  led  to 
general  peritonitis  and  death  if  early  operation  had  not  been 
instituted.  In  one  case  the  rapid  rise  in  the  leucocytes  was 
practically  the  only  clinical  evidence  of  a  grave  abdominal  con- 
dition. The  patient,  a  boy,  suffered  from  an  attack  of  pain  and 
nausea,  and  vomiting  followed  a  few  hours  after  taking  a  good 
deal  of  indigestible  food.  When  the  stomach  relieved  itself 
there  was  no  further  pain  and  no  further  abdominal  symptoms. 
After  twenty-four  hours  the  leucocytes  were  17,000.     A  leuco- 


132  BLOODGOOD, 

cytosis  of  17,000  in  a  patient  a  number  of  hours  after  taking 
food  would  make  one  suspicious  of  an  inflammatory  lesion.  In 
thirty  hours  the  leucocytes  were  17,000,  and  in  thirty-six  hours 
35,000.  The  highest  temperature  was  100°.  There  were  prac- 
tically no  abdominal  symptoms,  except  the  history  of  a  short 
attack  of  colic  and  vomiting  following  indigestible  food.  Be- 
cause of  this  rapid  rise  and  the  high  leucocyte-count  (35,000), 
it  was  considered  safer  to  explore  the  abdomen.  A  gangrenous 
appendix  with  beginning  purulent  pelvic  peritonitis  was  found. 
A  second  and  almost  similar  case  was  observed  when  the  leu- 
cocytes rose  from  13,000  to  24,000  in  twenty  hours  after 
the  beginning  of  the  first  colicky  pain,  the  first  count  being 
fourteen  hours  after  the  beginning  of  the  pain.  In  this  case 
there  were  in  addition  marked  clinical  signs  of  appendicitis. 
In  a  third  case,  with  very  slight  local  signs,  the  leucocytes 
rose  rapidly  from  13.000  to  23,000  in  twenty  hours  (first  count 
sixteen  hours). 

These  three  cases  of  gangrenous  appendicitis  I  report  in  de- 
tail because  they  demonstrate  the  great  diagnostic  importance 
of  the  leucocyte-count. 

Case  I. — Observed  by  Dr.  Thomas  R.  Brown,  in  this  city,  communi- 
cated to  me  personally,  is  perhaps  the  most  important.  The  patient, 
a  boy,  aged  eleven  years,  indulged  freely  one  Saturday  night,  about  8 
o'clock,  in  strawberry  ice  cream  and  soda-water  ;  at  4  o'clock  the  next 
morning  he  was  awakened  with  severe  epigastric  colic,  nausea,  and  vomit- 
ing. The  patient  was  seen  by  Dr.  Brown  at  8  a.m.  (four  hours);  tem- 
perature 98°;  pulse,  76.  He  was  given  a  Seidlitz  powder  and  powders  of 
subnitrate  of  bismuth.  The  abdominal  examination  was  negative.  He 
was  seen  again  at  10  a.m.  (six  hours),  no  change  in  the  symptoms;  no 
nausea  or  vomiting.  At  6  p.  m.  (twelve  hours)  the  temperature  was 
98.8°;  pulse,  86.  There  had  been  a  stool ;  the  urine  was  voided  without 
pain  ;  he  was  apparently  very  comfortable,  and  complained  of  no  pain ; 
abdominal  palpation  was  negative  ;  he  looked,  however,  a  little  lan- 
guid. There  was  nothing  in  the  clinical  picture  to  suggest  that  the 
condition  was  anything  more  than  that  to  be  explained  by  indigestion. 
On  Monday  morning  at  8  o'clock  (twenty-eight  hours  after  the  attack  of 
colic)  his  temperature  was  99  4°  ;  pulse,  95.     He  had  passed  a  com- 


BLOOD     EXAMINATIONS    AND    SURGICAL     DIAGNOSIS.       I33 

fortable  night;  no  nausea  or  vomiting;  no  abdominal  symptoms  ;  but 
he  looked  a  little  more  depressed.  The  leucocyte-count  at  this  time 
was  17,000.  (A  leucocytosis  twenty-eight  hours  after  an  attack  of  ab- 
dominal colic  in  a  patient  taking  practically  no  food  is  an  indication 
of  some  inflammatory  condition.)  At  11  o'clock  the  leucocyte-count 
was  17,500;  temperature,  100°;  pulse,  100;  but  no  abdominal  signs. 
At  4  o'clock  (thirty-six  hours  after  the  beginning  of  the  colic)  the  leu- 
cocyte-count was  35,000;  temperature,  100.6°;  pulse,  100.  For  the 
first  time  in  the  right  iliac  fossa  there  seemed  to  be  a  little  swelling; 
no  marked  muscle  spasm  or  tenderness.  He  did  not  complain  of  pain 
when  he  voided  urine.  This  rapid  and  high  rise  in  leucocytes,  even 
without  abdominal  sji^mptoms,  but  following  abdominal  colic,  was  con- 
sidered by  Dr.  Brown,  his  physician,  and  Dr.  Finney,  the  consulting 
surgeon,  a  sufficient  indication  for  exploration  of  the  abdomen.  On 
opening  the  abdomen,  an  appendix,  eight  inches  in  length  and  extend- 
ing into  the  pelvis,  was  found.  The  appendix  was  gangrenous  for  at 
least  two-thirds  of  its  length,  and  perforated  at  its  tip  ;  no  adhesion, 
and  no  localization.  The  pelvis  was  filled  with  cloudy  fluid ;  the  in- 
testines in  the  pelvis  and  right  iliac  fossa  were  injected,  covered  with 
a  little  fibrous  exudate  and  cloudy  fluid.  Cultures  were  not  taken. 
The  patient  recovered. 

In  this  case  the  rise  in  leucocytes  was  practically  the  only 
indication  for  operation.  There  were  no  previous  attacks  of 
appendicitis,  and  the  only  clinical  manifestation  pointing  to  the 
appendix  was  the  onset  of  the  abdominal  colic  associated  with 
nausea  and  vomiting. 

Case  II.,  recently  observed  by  Dr.  Mitchell  and  myself,  resembles 
Dr.  Brown's  observation  in  the  rapid  rise  in  the  leucocytes,  but  was 
associated  in  this  instance  with  distinct  abdominal  symptoms.  The 
patient,  a  boy,  aged  eighteen  years,  who  also  filled  his  stomach  one 
Saturday  night  with  indigestible  food,  experienced,  about  six  hours 
later,  intense  abdominal  colic,  which  was  worse  on  the  right  side,  fol- 
lowed in  four  hours  by  excessive  nausea  and  vomiting.  The  abdominal 
colic  continued  all  night,  and  when  he  voided  urine  it  gave  him  some 
pain.  He  walked  to  the  hospital,  and  was  first  examined  about  i  p.m. 
Temperature,  101°;  leucocytes,  13,000.  Both  recti  muscles  were  held 
tense,  but  the  muscle  rigidity  was  more  marked  on  the  right  side.  The 
clinical  picture  at  this  time  was  sufficient,  without  the  leucocyte-count, 


134  BLOODGOOD, 

to  make  a  diagnosis  of  pelvic  appendicitis.  His  parents  were  sent  for 
at  once,  but  refused  operation  until  6  p.  m.,  so  that  he  was  not  operated 
on  until  twenty  hours  after  the  beginning  of  the  attack.  He  was  first 
seen  at  fourteen  hours.  At  fifteen  hours  the  temperature  was  102°; 
pulse,  112;  respiration,  28;  leucocytes,  15,600.  In  sixteen  hours, 
leucocytes,  16,000.  In  eighteen  hours,  temperature,  104°;  pulse,  112; 
respiration,  28;  leucocytes,  19,000.  In  twenty  hours,  temperature, 
103.4°;  pulse,  116;  respiration,  20;  leucocytes,  24,800.  There  had 
been  no  nausea  or  vomiting  since  the  first  attack  at  lo'clock  the  night 
before.  The  muscle  rigidity  and  tenderness  increased.  At  the  ope- 
ration a  very  long  appendix  was  found  situated  in  the  pelvis,  its  distal 
portion  being  two  thirds  gangrenous  ;  no  perforation.  The  pelvis  and 
the  lower  portion  of  the  abdominal  cavity  were  filled  with  cloudy 
fluid.  The  intestines  in  the  pelvis  were  injected.  Cultures  :  bacilli, 
but  no  streptococci.     The  patient  made  an  uninterrupted  recovery. 

Case  III.  was  observed  in  the  hospital ;  the  patient,  one  of  the  hos- 
pital residents,  aged  twenty-eight  years,  was  taken  with  abdominal 
colic  and  slight  diarrhoea,  a  condition  not  uncommon  with  the  residents 
during  the  hot  summer  months.  At  the  end  of  sixteen  hours  the  tem- 
perature was  101°;  leucocytes,  13,000.  There  was  no  distinct  muscle 
spasm,  but  a  slight  area  of  tenderness  on  deep  palpation  at  the  outer 
border  of  the  right  rectus  muscle  ;  no  nausea  or  vomiting.  Also  about 
this  time  micturition  gave  a  little  pain.  At  the  end  of  twenty  hours 
the  temperature  was  101.6°;  leucocytes,  23,000;  the  patient  vomited 
for  the  first  time.  The  patient  was  immediately  prepared  for  operation, 
which  was  performed  twenty-two  hours  after  the  beginning  of  the  attack. 
The  temperature  just  before  the  operation  was  104.2°  ;  pulse,  80,  and  for 
the  first  time,  during  the  preparation  for  operation,  muscle  spasm  was 
noted.  At  the  operation  by  Dr.  Halsted  the  entire  appendix  was  gan- 
grenous and  situated  in  the  pelvis  ;  in  its  centre  over  one  hard  con- 
cretion the  wall  was  very  thin  ;  the  pelvis  was  filled  with  cloudy  fluid 
containing  the  bacillus  coli  communis.     The  patient  recovered. 

^laiU  Appendicitis  Distended  with  Pus.  Operation.  Recovery. 
There  are  five  cases  in  this  group;  in  all  the  localized  symp- 
toms were  sufficient  to  indicate  immediate  operation,  due,  per- 
haps, to  the  great  tension  of  the.  thickened  and  inflamed 
appendix,  which  was  distended  with  pus,  but  not  yet  gan- 
grenous.    Such  a  condition  is  one  of  great  danger,  because  an 


i 


BLOOD    EXAMINATIONS     AND    SURGICAL     DIAGNOSIS.       I35 

appendix  distended  with  purulent  material  containing,  without 
much  doubt,  bacteria  of  great  virulence,  might  perforate  at  any 
moment  and  discharge  into  an  unprotected  peritoneal  cavity. 
Fortunately,  in  these  five  cases  the  operation  was  performed  in 
time.  Two  cases  were  admitted  twenty-four  hours  after  the 
attack — in  one  the  leucocytes  were  15,000;  in  the  other,  19,000. 
The  local  signs  in  the  patient  in  which  the  leucocyte-count  was 
only  15,000  was  less  marked,  the  pus  in  the  appendix  was 
of  smaller  quantity,  the  walls  of  the  appendix  thickened  and 
under  less  tension.  What  would  have  happened  if  observed  a 
number  of  hours  longer  is  difficult  to  tell.  Two  cases  were 
admitted  forty-eight  hours  after  the  beginning  of  the  attack, 
one  with  a  leucocyte-count  of  17,000,  with  a  second  count  in 
two  hours,  just  before  the  operation,  of  20,000.  The  other  of 
21,000,  second  count  of  28,000.  A  third  case,  admitted  on 
the  second  day,  observed  five  hours,  showed  a  rising  leucocyte- 
count  from  18,000  to  35,000.  In  these  three  cases  the  clinical 
picture  was  a  marked  one,  and  the  appendix  was  not  much  thick- 
ened, and  under  great  tension.  In  only  one  of  these  five  cases 
was  there  a  walling  off  of  the  appendix  by  peritoneal  adhesion  of 
exudate,  and  it  seems  fair  to  infer  that  a  perforation  would  have 
been  followed  by  a  very  virulent  and  perhaps  fatal  peritonitis. 

Appendicitis.  General  Pei'itonitis.  Operation.  The  correct 
interpretation  of  the  leucocyte  count  in  this  group  of  cases  is 
difficult,  because  in  the  majority  of  cases  it  is  hard  to  estimate 
the  duration  of  the  peritonitis.  Observations  seem  to  demon- 
strate that  in  the  early  hours  of  peritonitis  there  is  a  rapid 
rise  in  the  leucocytes,  which,  however,  soon  falls.  These  cases 
have  been  grouped  according  to  the  duration  of  the  attack  and 
not  to  the  approximate  duration  of  the  peritonitis.  Five  cases 
have  been  observed,  in  each  of  which  the  beginning  of  the 
attack  was  within  forty-eight  hours.  Three  cases  recovered. 
One  operated  on  sixteen  hours  after  the  beginning  of  the  attack, 
with  a  leucocytosis  of  14,000;  i,  twenty-four  hours,  with  a 
leucocytosis  of  32,000;  and  i,  thirty-six  hours,  with  a  leuco- 
cytosis of  36,000.  In  these  3  cases  there  were  distinct  local 
symptoms,  but    slight    general   abdominal    symptoms.     There 


136  ^  BLOODGOOD, 

was  no  distention  of  the  intestine;  the  exudate  was  chiefly 
purulent;  in  the  exudate  in  the  general  peritoneal  cavity  only 
the  colon  bacilli  were  found,  and  no  streptococci.  In  i  case 
observed  forty-eight  hours  after  the  beginning  of  the  attack, 
and  operated  on  at  once,  the  leucocyte-count  was  25,000.  The 
general  abdominal  symptoms  masked  the  local  symptoms,  the 
patient  was  very  ill,  the  intestines  were  distended,  streptococci 
were  present,  and  the  patient  died.  One  patient  was  observed 
in  the  hospital.  Twenty  hours  after  the  beginning  of  slight 
abdominal  colic  localized  in  the  right  iliac  fossa,  the  leucocytes 
were  8000;  six  hours  later,  or  thirty-six  hours  after  the  begin- 
ning of  the  attack,  the  leucocytes  were  20,000.  Clinically,  the 
patient  was  not  very  ill,  but  on  account  of  the  rise  of  the  leuco- 
cytes from  8000  to  20,000,  operation  was  performed.  The  ap- 
pendix was  perforated  and  surrounded  by  a  few  drachms  of  puru- 
lent material ;  this  pus  was  not  walled  off  by  adhesions ;  the 
general  peritoneum  was  slightly  injected;  it  appeared  as  if  there 
was  beginning  general  peritonitis.  After  the  operation  the  leuco- 
cytes continued  to  rise  for  twelve  hours  up  to  26,000;  then 
within  the  next  twelve  hours  fell  to  11,000,  the  patient  dying, 
with  a  clinical  picture  of  peritonitis  which  was  found  at  autopsy. 
In  this  case  the  streptococci  were  present.  In  5  cases  admitted 
three  days  after  the  onset  of  the  symptoms,  all  showing  the 
clinical  picture  of  peritonitis,  the  leucocyte-counts  in  4  were 
11,000,  1 1,000,  13,000,  and  14,000.  These  4  cases  were  fatal. 
The  fifth  case,  whose  leucocyte-count  was  highest  (17,000),  re- 
covered. The  cultures  from  the  peritoneal  cavity  in  this  case 
showed  bacillus  coli  communis.  These  counts  and  others  not 
given  in  this  short  paper  seem  to  demonstrate  that  within 
forty-eight  hours  after  the  beginning  of  an  attack  a  very  high 
leucocytosis  is  suggestive — but  not  at  all  positive — of  begin- 
ning peritonitis,  and  that  the  leucocyte-count  does  not  help  us 
with  regard  to  prognosis.  After  the  second  day,  in  cases  in 
which  the  peritonitis  has  been  present  longer,  we  have  never 
observed  a  recovery  with  a  low  leucocyte-count.  If  the  leuco- 
cytosis still  remains  high  at  this  period,  the  prognosis  seems 
better  for  the  ultimate  recovery  after  operation. 


J 


BLOOD    EXAMINATIONS    AND    SURGICAL     DIAGNOSIS.       I37 

Appendicitis.  Abscess.  So  far,  in  our  observations,  we  have 
but  2  cases  of  abscess  with  leucocyte-counts  observed  within 
forty-eight  hours  after  the  beginning  of  the  attack.  In  i  the 
leucocytosis  was  18,000,  and  there  were  distinct  local  signs, 
although  on  account  of  the  muscle  spasm  it  was  impossible  to 
make  out  a  collection  of  pus.  This  patient  was  operated  on 
twenty-four  hours  after  the  beginning  of  the  attack.  A  small 
abscess  was  found  about  the  perforated  appendix,  the  collec- 
tion of  pus  was  well  walled  off,  but  there  was  beginning 
peritonitis  demonstrated  by  cloudy  sterile  fluid  and  fibrinous 
exudate  on  the  intestines  about  the  abscess.  The  patient  re- 
covered. 

The  low  count,  ii.ooo,  twenty-four  hours  after  the  onset, 
is  hard  to  explain.  This  patient  had  marked  local  signs  of  in- 
flammation, but  no  definite  tumor.  At  operation  there  was 
evidence  that  there  had  been  recurrent  attacks,  the  adhesions 
about  the  appendix  were  very  firm,  but  the  collection  of  pus 
was  very  small. 

Between  two  and  seven  days  there  have  been  27  cases  of 
appendicitis,  with  abscess.  In  6  cases  the  leucocyte-counts 
have  been  between  11,000  and  12,000;  the  others  higher,  the 
majority  between  18,000  and  30,000.  The  interpretation  of  the 
leucocytes  at  this  stage  of  the  disease,  especially  between  the 
third  and  seventh  day,  is  a  difficult  one.  A  high  leucocytosis 
after  the  second  day  of  the  disease,  in  the  majority  of  instances, 
is  an  indication  of  gangrene,  pus  in  the  appendix,  abscess,  or 
peritonitis.  A  low  leucocytosis  has  been  associated  with  an 
acute  attack,  getting  well  or  completely  over,  but  in  a  few 
instances  it  has  been  associated  with  abscess  and  peritonitis.  In 
these  6  cases  of  abscess,  with  leucocyte-counts  between  11,000 
and  12,000,  4  were  distinctly  getting  well,  the  abscess  well 
walled  off";  in  2  the  patients  were  very  ill,  and  there  was  evi- 
dence of  beginning  peritonitis  ;    i  died. 

The  interpretation  of  the  leucocytosis  in  the  cases  of  appen- 
dicular abscess  between  one  week  and  one  month  has  already 
been  discussed  with  the  group  of  cases  of  chronic  and  subacute 
appendicitis. 


138  BLOODGOOD, 

Conclusions  in  Regard  to  the  Interpretation  of  the  White  Blood- 
count  in  Appendicitis.  Although  there  are  exceptions  to  the 
rule,  a  rising  leucocytosis  is  an  indication  for  an  operation.  In 
the  majority  of  instances  if  the  leucocytes  reach  18,000  before 
forty-eight  hours,  it  has  been  an  indication  of  an  advanced 
pathological  lesion.  For  example,  excessive  exudate  with  a 
diffuse  appendicitis,  gangrene,  or  an  appendix  distended  with 
pus,  abscess,  or  beginning  peritonitis.  When  the  leucocytes 
have  been  below  18,000,  or  when  counted  a  number  of  times, 
have  fallen  in  number,  the  patients  have  recovered  without 
operation.  With  a  fall  in  the  leucocytes  there  has  been  asso- 
ciated a  rapid  cessation  of  the  local  symptoms,  or,  if  operated 
on,  the  appendix  has  been  the  seat  of  but  slight  diffuse  inflam- 
mation. 

Observed  later  in  the  attack,  especially  after  the  fourth  day, 
a  high  leucocytosis  has  usually  been  associated  with  localized 
abscess  or  peritonitis.  It  is  to  be  remembered,  however,  that  it 
is  possible  to  have  an  abscess  with  a  low  leucocyte-count.  Out 
of  the  56  cases  of  appendicitis  with  abscess,  14  have  had  a  leuco- 
cyte-count between  6000  and  12,000;  the  remainder  have  been 
higher,  the  majority  over  20,000  ;  the  usual  count  is  between 
20,000  and  25,000,  one  count  30,000,  one  60,000. 

It  is  also  to  be  remembered  that  with  peritonitis  there  may 
be  a  very  low  leucocyte-count.  This,  so  far  in  our  observations, 
has  been  associated  with  an  extreme  septic  condition  of  the 
patient,  and  in  every  case  death  has  followed.  These  low  leu- 
cocyte-counts have  been  observed  in  patients  admitted  to  the 
hospital  three  days  or  longer  after  the  beginning  of  the  attack; 
so  it  is  difficult  to  ascertain  the  exact  duration  of  the  peritonitis. 
Observations  are  sufficient  to  indicate  that  in  the  majority  of 
instances  beginning  peritonitis  is  associated  with  the  rise  in  the 
leucocytes,  which,  however,  rapidly  falls  as  the  patient  becomes 
more  septic. 

In  a  general  way  we  may  feel  that  a  patient  admitted  with 
symptoms  of  peritonitis,  with  a  high  leucocyte-count,  has  better 
chance  for  recovery.  The  leucocyte-count  simply  indicates, 
however,   a   short   duration    of  the   peritonitis.      The    positive 


k 


BLOOD     EXAMINATIONS    AND    SUKGICAL     DIAGNOSIS.       1 39 

prognosis  depends  more  upon  the  bacteriological  findings  than 
upon  the  leucocytosis.  So  far  in  our  observations  in  the  4 
cases  which  recovered,  the  cultures  demonstrated  the  presence 
of  colon  bacilli  and  other  bacilli,  but  no  streptococci. 

Before  more  definite  conclusions  can  be  made  in  regard  to 
the  interpretation  of  leucocytosis  in  appendicitis  we  must 
have  more  observations,  especially  observations  of  cases 
from  the  beginning  of  the  attack,  where  we  have  a  number 
of  counts.  There  are  sufificient  observations,  however,  to 
make  a  careful  surgeon  insist  upon  a  blood-count  in  every 
case  of  acute  abdominal  lesion,  and  during  the  first  forty-eight 
hours  to  have  counts  made  every  four  or  six  hours.  A  rapid 
rise  in  the  leucocytes,  especially  above  18,000,  should,  in  my 
opinion,  be  a  sufficient  indication  for  exploration,  even  in  those 
cases  in  which  the  local  symptoms  are  very  slight.  In  the  few 
exceptions  in  which  the  local  symptoms  are  sufficiently  distinct 
to  indicate  an  operation,  a  low  leucocytosis  should  not  influence 
as  to  delay  operation. 

Leucocytosis  in  Intestinal  Obstruction.  Dr.  Harvey  Gushing,  I 
think,  was  the  first  in  this  country  to  call  attention  to  the  leuco- 
cytosis associated  with  intestinal  obstruction.  I  referred  to  this 
in  Johns  Hopkins  Hospital  Reports,  vol.  vii.,  1898,  p.  332,  in  rela- 
tion to  leucocytosis  in  strangulated  hernia.  Since  Cushing's  first 
count  in  August,  1898,  the  leucocytes  have  been  estimated  in 
almost  every  case  of  intestinal  obstruction,  and  in  this  group 
of  cases  the  increase  in  the  number  of  white  cells  associated 
even  with  very  slight  symptoms  of  intestinal  obstruction,  has 
been  found  to  be  of  great  value  in  the  early  recognition  of  the 
obstruction,  frequently  before  the  clinical  signs  were  positive. 
We  have  a  large  group  of  cases  which  have  demonstrated  that 
within  twelve  hours  after  the  beginning  of  the  obstruction  the 
leucocyte-count  may  rise  to  20,000.  Within  the  first  twelve  to 
twenty-four  hours  a  few  observations  would  demonstrate  that  if 
the  leucocyte-count  rises  above  25,000  or  30,000  the  probabili- 
ties are  that  one  will  find  gangrene  of  the  obstructed  loop  or 
beginning  peritonitis.  If  observed  on  the  second  or  third 
day    after    the    beginning    of  the    symptoms   it   is   difficult    to 


140  BLOODGOOD, 

make  a  differential  diagnosis  with  regard  to  gangrene  or 
peritonitis.  After  the  third  day,  in  cases  in  which  there  is 
no  gangrene  and  no  peritonitis,  or  in  which  the  auto-intoxi- 
cation is  not  yet  very  grave,  the  leucocytes  still  remain  high, 
15,000  to  23,000,  according  to  the  degree  of  obstruction  :  com- 
plete, higher;  partial,  lower.  In  the  presence  of  gangrene, 
peritonitis,  or  grave  auto-infection,  the  leucocytes  begin  to  fall. 
If  the  patient  is  admitted  after  the  third  or  fourth  day  with  a 
history  of  intestinal  obstruction,  and  still  has  a  high  leucocyte- 
count,  the  prognosis  is  good  for  operation.  If  the  count  is  low, 
and  especially  if  it  is  below  10,000,  the  probabilities  are  that 
you  will  find  at  operation  extensive  gangrene  or  peritonitis ;  or 
the  patient  will  be  so  depressed  by  the  auto-intoxication  that 
reaction  does  not  follow  relief  of  the  obstruction. 

In  5  cases  of  strangulated  hernia  admitted  within  twelve  hours 
after  the  rupture  had  become  irreducible,  the  leucocyte-counts 
were  10,000,  15,000,  18,000,  and  in  2  cases  20,000.  In  all  of 
these  cases  the  sac  contained  congested  intestine.  All  the  cases 
recovered  after  operation.  In  the  one  in  which  the  leucocytosis 
was  20,000  we  were  able  to  reduce  the  rupture  with  ice  bags,  the 
leucocytes  falling  in  three  hours  to  18.000,  and  in  twenty-four 
hours  to  12,000.  In  i  case  the  patient  left  home  with  an  irre- 
ducible hernia  of  some  hours'  duration;  but  during  the  journey 
of  some  fourteen  hours  on  a  railroad  train  the  rupture  became 
reduced,  and  on  admission  the  leucocyte-count  was  but  6000, 
which  seemed  to  exclude  the  possibility  of  reduction  en  bloc  of 
the  rupture.  The  patient  recovered,  and  some  days  later  was 
operated  on  for  the  reducible  hernia. 

An  observation  of  my  own  demonstrates  the  importance  of 
even  a  slight  rise  in  the  leucocytes  as  an  aid  to  early  recognition 
of  obstruction.  The  patient  had  previously  been  operated  on  in 
the  hospital  for  acute  appendicitis  with  abscess,  and  the  wound 
had  been  drained.  This  clinical  history,  of  course,  pointed  to 
the  possibility  of  obstruction  from  adhesions.  Some  four  months 
after  this  operation  he  came  to  the  hospital  complaining  of  ab- 
dominal pain  of  six  hours'  duration  in  the  region  of  the  scar. 
There  had  been  no  nausea  or  vomiting,  and  abdominal  examina- 


BLOOD     EXAMINATIONS    AND    SURGICAL     DIAGNOSIS.       I4I 

tion  was  negative.  The  pain,  however,  was  quite  severe,  and 
was  sHghtly  remittent,  as  if  coincident  with  peristaltic  action, 
although  such  intestinal  movements  could  not  be  made  out 
during  a  long  and  careful  examination.  The  leucocyte-count  in 
four  hours  rose  to  12,000.  There  was  no  fever,  and  the  patient 
had  not  taken  any  food. 

In  view  of  the  history  and  rise  of  the  leucocytes  an  explora- 
tory operation  was  done.  It  was  found  that  the  omentum  and 
caecum  were  adherent  to  the  old  wound,  and  to  the  Ccijcum  was 
an  adherent  knuckle  of  small  intestine,  producing  a  partial  ob- 
struction. The  ileum  from  this  point  of  obstruction  for  a  dis- 
tance of  one  foot  was  collapsed;  in  the  other  direction  slightly 
distended.  The  operation  required  some  time  in  order  to  sep- 
arate all  the  adhesions,  and  it  was  fortunate  that  an  early  explo- 
ration was  done,  when  the  patient  was  in  sUch  a  good  condition 
that  prolonged  anaesthesia  was  not  contraindicated. 

The  Leucocyte-counts  in  Cholecystitis. 

Acute  Cholecystitis.  In  7  cases  the  leucocyte-counts  have  varied 
from  20,000  to  26,000.  Two  cases  admitted  at  the  end  of  the 
attack,  with  no  symptoms,  had  leucocyte-counts  of  8000.  The 
rise  in  the  leucocytes  associated  with  symptoms  of  acute  chole- 
cystitis does  not  seem  to  demand  the  same  imperative  early 
operation  as  similar  counts  associated  with  symptoms  of  appen- 
dicitis, because  here  the  danger  of  peritonitis  or  abscess  is  a 
very  distant  one.  We  have  observed  2  cases  from  the  very 
onset  in  the  hospital.  One  case  was  of  special  interest  because 
the  cholecystitis  occurred  during  convalescence  from  typhoid 
fever. 

The  patient,  a  woman,  aged  forty-nine  years,  was  admitted  to  the 
medical  side,  apparently  at  about  the  tenth  day  of  typhoid  fever  ;  the 
leucocyte  count  was  6000.  During  the  forty-two  days  she  had  a  more 
or  less  uninterrupted  typical  typhoid  attack,  with  no  rise  in  leucocytes. 
On  this  day  (the  forty-second),  at  4  o'clock  in  the  morning,  the  tem- 
perature, which  had  been  normal  for  some  days,  rose  to  101.7^,  and 
in  tour  hours  to  105.2°.  The  patient  complained  of  pain  in  the  ab- 
domen and  region  of  the  gall-bladder.     In  this  area  there  was  distinct 


142  BLOODGOOD, 

muscle  spasm,  but  on  account  of  muscle  spasm  no  tumor  could  be 
made  out.  Respiration,  56;  pulse,  128;  the  leucocytes  had  risen  to 
16,500;  in  three  hours  to  22,000.  The  operation  was  performed  at 
this  time,  five  hours  after  the  beginning  of  the  attack  ;  the  gall  bladder 
contained  gallstones  and  slightly  purulent  bile ;  cultures,  the  bacilli 
coli  communis. 

The  second  case  was  rather  a  feeble  man,  aged  sixty-five  years,  who 
on  November  3,  1899,  under  ether  anaesthesia,  had  been  operated 
on  for  a  very  huge  lipoma  of  the  thigh ;  following  the  operation 
pneumonia  associated  with  a  high  leucocytosis.  For  some  days  the 
temperature  had  been  normal,  with  no  leucocytosis.  On  November 
15th,  in  the  morning,  he  complained  of  abdominal  pain  in  the  gall- 
bladder region,  slight  nausea,  and  vomiting.  Examination  of  the 
abdomen  was  negative.  This  attack  of  pain  lasted  a  few  hours,  and 
then  disappeared  ;  temperature,  100°  ;  pulse,  99.  During  the  afternoon 
he  had  slight  attacks  of  pain.  The  next  morning,  twenty-four  hours  after 
the  first  gall-bladder  colic,  associated  with  pain,  the  temperature  rose 
to  102°,  in  a  few  hours  to  103°  ;  leucocytes,  13,000.  In  the  gall- 
bladder area  there  was  distinct  tenderness  and  muscle  spasm,  and  on 
deep  palpation  one  felt  a  tumor  descending  on  inspiration.  The 
leucocytes  rose  from  13,000  to  22,000  in  six  hours.  There  were  no 
signs  of  pneumonia  or  of  malaria ;  clinically  the  picture  was  that  of 
acute  cholecystitis.  The  operation  was  performed  under  cocaine 
anaesthesia,  the  gall  bladder  was  distended  and  contained  purulent 
material  and  a  few  gallstones.  The  cultures  showed  bacilli  coli  com- 
munis and  staphylococcus  pyogenes  aureus.     The  patient  recovered. 


J 


BLOOD     EXAMINATIONS    AND    SURGICAL    DIAGNOSIS.       I43 


DISCUSSION. 

Dr.  B.  Farcjuhar  Curtis,  of  New  York,  in  discussing  these  papers, 
said  :  I  am  surprised  to  learn  by  the  reports  from  Boston  of  the  ab- 
sence of  leucocytosis  after  operations  done  under  ether  and  local  anaes- 
thesia. At  St.  Luke's  Hospital  we  have  made  a  series  of  these  obser- 
vations, and  while  it  is  true  they  have  been  done  by  the  resident  staff, 
yet  they  have  been  very  consistent  in  their  results.  I  feel  sure  they 
are  not  lacking  in  accuracy,  and  in  the  majority  of  cases  we  have 
found  a  marked  leucocytosis  which  has  no  reference  to  the  length  of 
the  anaesthesia,  to  the  amount  of  the  drug,  or  to  the  severity  of  the 
operation.  Lately,  I  have  been  interested  in  three  or  four  operations 
done  under  intraspinal  anaesthesia,  and  in  those  operations  leucocyte- 
counts  were  made  at  intervals  of  from  one  to  two  hours.  A  progres- 
sive increase,  was  found  corresponding  to  that  found  under  general 
anaesthesia.  In  the  latter  case  we  have  both  the  effect  of  the  drug 
itself  upon  the  blood  and  of  the  other  inhalation  upon  the  lung,  while 
in  the  local  anaesthesia  we  have  simply  the  effect  of  the  cocaine  and 
the  injection  of  fluid  into  the  spinal  canal,  but  the  increase  in  leuco- 
cytes was  noted  in  every  case  for  at  least  five  hours.  It  then  remained 
stationary,  sometimes  reaching  as  high  as  18,000,  and  came  down 
slowly  during  the  next  forty-eight  hours.  There  was  no  infection  in 
any  of  these  cases,  but  in  one  of  them,  although  a  small  part  of  the 
flap  sloughed,  the  leucocyte-count  did  not  remain  high.  I  believe 
that  operative  leucocytosis  may  be  assumed  to  be  a  fixed  factor,  and  it 
is  therefore  impossible  to  use  the  leucocyte-count  in  determining  the 
presence  or  absence  of  infection  in  the  first  two  days  after  operation. 
I  feel  that  the  gentleman  from  Baltimore  ranks  the  value  of  the  leuco- 
cyte-count too  high.  I  think  it  is  of  equal  value  with  the  temperature 
and  pulse,  but  is  not  higher.  We  meet  too  many  contradictory  cases. 
I  recall  the  case  of  a  man,  aged  about  forty-five  years,  who  was  ad- 
mitted to  my  wards  at  night  with  symptoms  of  appendicitis.  The 
leucocyte-count  was  only  7500,  although  the  temperature  was  high 
(102°),  and  I  postponed  operation  until  the  next  day.  By  that  time 
the  temperature  had  dropped  to  normal,  and  the  tenderness,  which 
was  very  acute  the  night  before,  had  considerably  lessened,  but  four 
days  later  I  obtained    consent  to  do  an  exploratory  operation.     A 


144       BLOOD     EXAMINATIONS    AND    SURGICAL     DIAGNOSIS. 

movable  mass  about  the  size  of  the  end  of  the  thumb  was  found  in 
the  region  of  the  appendix,  and  there  was  a  limited  collection  of 
pus,  i.e.,  a  retroperitoneal  abscess.  These  conditions  were  difficult 
of  explanation,  as  there  was  an  absence  of  leucocytosis,  although  the 
patient  was  not  thoroughly  septic,  and,  although  the  collection  was 
walled  off,  the  man's  high  temperature  showed  absorption  of  toxins. 


FRACTURES  OF  THE  PELVIS  FROM  VIOLENCE  EX- 
ERTED   THROUGH   THE   LONG   AXIS    OF    THE 
FEMURS,  BEING    A    COMPARATIVE   STUDY 
OF  THE  RELATIVE  STRENGTH  OF  THE 
NECK  OF   THE   FEMUR   AND   THAT 
OF     THE     PELVIS     WHEN     THE 
VIOLENCE  IS  TRANSMITTED 
THROUGH    THE    LONG 
AXIS     OF    THE 
FORMER. 


By  OSCAR  H.  ALLIS,  M.D., 

PHILADELPHIA. 


Were  a  person  to  be  caught  between  two  cars,  or  crushed 
between  falling  rocks,  a  fracture  of  the  pelvis  would  be  attrib- 
uted to  direct  violence.  But  when  one  reads  of  a  bale  of  cotton 
falling  upon  a  laborer's  back,  producing  fatal  injuries,  and  at  the 
autopsy  a  fracture  of  the  pelvis,  with  rupture  of  the  bladder,  is 
found,  the  evidence  of  direct  violence  is  perfectly  clear ;  but  just 
how  a  soft,  vulnerating  body,  like  a  bale  of  cotton,  could  fracture 
the  pelvis  is  not  clear,  unless  one  imagine  that  the  victim's  body, 
driven  downward  by  the  weight  of  the  cotton,  struck  upon  some 
hard,  irregular  substance,  thus  producing  a  crush  similar  to  that 
between  two  cars. 

Plausible  as  such  an  explanation  of  the  fracture  may  seem, 
and  possibly  correct  in  some  instances,  there  is  another  which 
seems  much  more  plausible,  viz.  :  that  the  blow  from  the  bale  of 
cotton,  striking  the  man  on  his  back,  forced  him  down  upon  his 
knees,  and  as  soon  as  the  knees  struck  the  ground,  and  could 
go  no  further,  the  unspent  force,  acting  upon  the  pelvis,  drove 

Am  Surg  lo 


146  ALL  IS, 

the  socket  against  the  head  of  the  femur,  and  thus  the  pelvic 
arch  received  a  strain  before  which  it  yielded.  This  explana- 
tion is  far  from  being  a  theoretical  one.  I  have  so  frequently 
fractured  the  pelvis  by  forcing  the  head  of  the  femur  against  the 
sockets  that  I  am  inclined  to  think  that  fractures  of  the  pelvis 
from  violence  through  the  long  axes  of  the  femurs  is  far  more 
frequent  than  fractures  from  direct  pressure. 

In  my  earlier  experimental  work  upon  the  cadaver  I  was 
inclined  to  the  belief  that  dislocations  of  the  femur  from  force 
exerted  through  the  long  axis  of  that  bone  were  infrequent,  and 
when  such  a  force  assumed  sufficient  magnitude  a  fracture  of 
the  neck  of  the  femur  or  of  the  rim  of  the  acetabulum  would 
be  the  more  probable  result.  A  wider  experience  has  compelled 
me  to  modify  this  belief,  and  to  assert  that  force  exerted  along 
the  long  axis  of  the  femur  will  (i)  frequently  fracture  the  pelvis, 
(2)  occasionally  produce  a  dislocation  backward,  but  (3)  7iot  in 
a  single  ijtstance  has  such  violence  produced  a  fracture  of  the 
neck  of  the  femur. 

The  reader  will  please  not  misunderstand  the  conditions  under 
which  this  statement  is  made.  Every  hospital  surgeon  knows 
the  frequency  of  fracture  of  the  neck  of  the  femur,  even  in 
middle  life,  from  violence,  while  the  ease  with  which  the  femoral 
neck  is  broken  in  the  aged  is  universally  known.  The  point  I 
wish  to  make  and  emphasize  is  that  when  fracture  of  the  neck 
of  the  femur  occurs  it  does  not  take  place  from  violence  ex- 
erted through  the  long  axis  of  the  shaft,  but  rather  from  vio- 
lence through  a  blow  upon  the  trochanter  or,  still  more  prob- 
ably, through  a  twist  of  the  femur. 

I  am  well  aware  that  violence  applied  cautiously  and  deliber- 
ately by  means  of  a  long  lever  cannot  be  expected  to  produce 
the  identical  injuries  that  would  result  from  the  momentum  of 
a  falling  body  or  a  fall  from  a  runaway  horse,  and  hence  my 
deductions  cannot  be  regarded  as  universally  applicable.  Be 
this  as  it  may,  the  result  of  violence  applied  cautiously  and  sys- 
tematically has  led  me  to  note  the  points  where  violence  under 
given  laws  will  explode,  and  when  the  evidence  is  clear  that 
violence  has  been  exerted  upon  the  knees  through  a  fall  upon 


FRACTURES    OF    THE    PELVIS.  I47 

them,  and  that  the  force  has  been  carried  through  the  long  axes 
of  the  femurs  to  the  pelvis,  I  would  be  very  far  from  assuring 
my  patient  that  there  was  no  fracture  simply  because  I  could 
find  none  in  any  part  of  the  femur. 

My  experiments  have  led  me  to  consider  the  surroundings  of 
the  accident.  Let  me,  for  example,  allude  to  persons  knocked 
down  by  a  rapidly  moving  carriage.  Death  has  followed  many 
such  accidents,  and  at  the  autopsy  the  pathologist  has  looked 
in  vain  for  the  track  of  the  wheel  to  account  for  fracture  of  the 
pelvis.  My  experiments,  in  which  the  pelvis  has  been  invari- 
ably fastened  to  a.  hard platik  and  the  violence  exerted  upon  the 
knees,  have  resulted  in  injuries  so  closely  allied  to  those  from 
run-over  injuries  that  I  am  persuaded  that  one  may  entertain  a 
serious  error  if  he  attributes  the  fractures  of  the  pelvis  invari- 
able to  the  wheel  of  a  carriage. 

In  my  experimental  work  I  have  not  arrived  at  the  degree  of 
exactness  that  enables  me  to  predict  what  the  result  of  violence 
to  a  certain  part  will  be.  I  have  applied  force  to  the  knee  when 
semiflexed,  the  pelvis  being  fixed  and  the  foot  resting  on  an 
immovable  block,  and  in  certain  instances  there  has  been  frac- 
ture of  the  tibia  near  the  knee,  depression  of  the  articular  sur- 
face of  the  tibia  and  femur,  dislocation  of  the  tibia  backward, 
fracture  of  the  acetabulum  and  fracture  of  the  rami  of  the 
ischium  and  pubes,  but  in  no  instance  have  I  fractured  the 
neck  of  the  femur. 

When  I  have  exerted  the  force  upon  the  femur  at  right 
angles  to  the  pelvis  I  have  produced  a  dislocation  backward — 
fracture  of  the  acetabulum  or  fracture  of  the  rami  of  pubes  and 
ischium  ;  but  in  no  instance  have  I  fractured  the  neck  of  the 
femur. 

The  following  demonstrations  were  then  made: 

A  cadaver  was  fixed  upon  the  table  and  the  lever  placed  over 
the  semiflexed  knee.  The  pressure  was  downward,  resulting  in 
fracture  of  the  tibia  and  fibula  above  the  ankle,  but  not  injuring 
the  neck  of  the  femur. 

The  lever  was  placed  above  the  knee  flexed  to  right  angle. 
Fracture  of  the  acetabulum  and  ramus  of  the  pubes  resulted. 


148  FRACTURES    OF    THE    PELVIS. 

The  femur,  with  flesh  removed,  was  laid  upon  the  table  so 
that  the  head  supported  one  end  and  the  condyles  the  other. 
The  shaft  was  two  or  three  inches  above  the  surface  of  the  table. 
The  lever  was  placed  over  the  middle  of  the  shaft.  The  elas- 
ticity of  the  femur  was  beautifully  demonstrated.  It  finally 
broke,  but  not  at  the  neck. 

The  femur,  with  flesh  removed,  was  placed  perpendicularly 
upon  a  pine  slab,  and  force  brought  to  bear  upon  the  condyloid 
end.  The  head  was  driven  deeply  into  the  slab  and  the  shaft 
finally  broken,  but  not  at  the  neck. 


ON  PANCREATITIS. 


By  a.  W.  mayo  ROBSON,  F.R.C.S., 

LEEDS,  ENGLAND, 

SENIOR  SURGEON  TO  THE  GENERAL   INFIRMARY    AT   LEEDS  ;    EMERITUS  PROFESSOR 

OF  SURGERY   IN   THE   YORKSHIRE  COLLEGE   OF   THE  VICTORIA   UNIVERSITY. 


Mr.  President:  I  must  first  thank  you,  sir,  and  the  Council 
for  the  great  honor  done  me  in  inviting  me  to  come  to  Balti- 
more and  take  part  in  the  proceedings  of  the  American  Surgi- 
cal Association,  which  I  consider  also  a  privilege  and  a  pleasure. 

Having  expressed  my  views  on  chronic  pancreatitis  and  its 
relation  to  cholelithiasis  at  the  London  Polyclinic  in  June,  1900, 
and  having  been  invited  to  open  the  discussion  on  Diseases  of 
the  Pancreas  "  at  the  International  Medical  Congress  at  Paris  in 
August  last,  I  almost  regretted  having  promised  to  give  this  paper 
before  the  American  Surgical  Association,  lest  it  might  appear 
as  if  I  were  simply  giving  a  rechauffe  of  my  views,  but  it  is  as- 
tonishing how  much  has  recently  been  written  on  the  subject. 
Not  only  have  my  observations  been  confirmed  by  numerous 
workers,  who  have  expressed  their  views  in  writing,  but  from 
conversations  that  I  have  had  with  surgeons  who  are  frequently 
operating  on  the  abdomen ;  nearly  all  have  had  one  or  more 
cases  which  they  had  diagnosed  as  gallstones  in  the  common 
duct,  for  which  they  had  operated,  but  finding  a  tumor  of  the 
head  of  the  pancreas,  they  had  simply  drained  the  gall-bladder 
and  given  a  bad  prognosis,  thinking  the  disease  to  be  cancer; 
and  only  on  the  complete  recovery  of  the  patients  had  wonder 
been  excited  and  some  other  explanation  sought  for.  More- 
over, my  own  experience  has  been  increased,  and  as  the  result* 
of  further  observations  I  have  views  to  advance  which  will, 
I  hope,  produce  a  useful  discussion. 


150  ROBSON, 

I  do  not  propose  to  weary  the  Association  with  a  recital  of 
many  cases,  a  number  of  which  have  been  reported  and  can 
easily  be  referred  to  if  wanted ;  but  I  should  like  to  give  what 
time  I  have  to  a  brief  consideration  of  the  relation  between  fat 
necrosis  and  hemorrhage,  to  the  relation  of  gallstones  and  pan- 
creatic diseases,  and  to  the  treatment  of  pancreatitis  generally. 

It  is  a  curious  fact  that,  although  surgeons  have  been  remov- 
ing gallstones  from  the  common  duct  for  a  little  over  ten  years — 
z".  (?.,  since  Courvoisier's  first  successful  choledochotomy  in  1890, 
and  that  although  the  subject  of  jaundice,  dependent  on  obstructed 
common  duct,  received  great  attention  from  physicians  many 
years  ago,  yet  until  comparatively  recently  it  never  seemed  to 
dawn  on  the  minds  of  clinical  observers  that  whatever  obstructs 
the  common  bile  duct  at  its  lower  end  must  also  of  necessity 
lead  to  an  obstruction  in  the  pancreatic  duct ;  and  although, 
since  the  description  of  the  disease  by  Charcot  as  intermittent 
hepatic  fever,  infective,  and  suppurative  cholangitis  have  been 
well  recognized  by  pathologists,  yet  infective  and  suppurative 
catarrh  of  the  pancreatic  ducts  have  even  yet  received  no  place 
in  the  medical  text-books,  which  means  in  reality  that  all  dis- 
eases of  the  pancreas,  except  those  producing  gross  organic 
changes,  such  as  cancer,  acute  pancreatitis,  cysts,  and  calculi, 
have  been  practically  ignored ;  yet  we  know,  both  by  post-mor- 
tem observation  and  by  surgical  experience,  that  under  similar 
conditions  the  pancreatic  ducts  participate  in  the  same  inflam- 
matory processes  as  the  bile  ducts. 

When  the  common  bile  duct  is  obstructed  the  objective  sign 
of  jaundice  at  once  demonstrates  the  fact ;  hitherto,  however, 
no  pathognomonic  sign  has  been  discovered  which  will  show 
conclusively  that  the  pancreatic  ducts  are  occluded,  unless  it  be 
the  extremely  rapid  loss  of  weight.  As  is  now  well  known,  the 
presence  of  fat  necrosis  does  afford  some  clue  and  a  very  im- 
portant one,  only  hitherto  discovered,  however,  when  the  abdo- 
men is  opened ;  but  even  for  fat  necrosis  to  take  place,  there 
must  probably  have  been  some  escape  of  the  fat-splitting  fer- 
ment from  the  gland,  and  therefore  the  affection  of  the  pancreas 
must  be  somewhat  advanced  before  the  sign  is  evident.    Glyco- 


ON    PANCREATITIS.  I5I 

suria,  lipuria,  and  fat  in  the  stools  occur  too  seldom  to  be  of 
much  use  in  the  diagnosis  of  pancreatic  disease,  though  when 
present  they  are  of  great  diagnostic  importance.  I  think  that 
physiological  chemistry  may,  perhaps,  help  us  in  the  diagnosis, 
and  though  our  observations  are  not  by  any  means  yet  complete, 
I  hope  that  some  researches,  at  present  being  conducted  on  cases 
under  my  care,  by  my  friend,  Mr.  P.  J.  Cammidge,  pathologist 
to  the  West  Riding  County  Council,  may  prove  of  practical  use, 
and  I  have  some  grounds  for  hope  that  by  an  examination  of 
the  urine  alone,  or  of  the  urine,  the  blood,  and  the  feces,  that 
we  may  have  some  assistance  in  the  diagnosis  of  these  difficult 
cases. 

The  pancreas  is  a  racemose  gland  well  supplied  with  blood, 
and  unlike  the  parotid,  the  lobules  of  which  are  well  supported 
by  fibrous  partitions,  its  tissues  are  comparatively  soft  in  con- 
sistence and  easily  bruised,  so  that  although  it  is  placed  in  the 
most  favorable  position  for  protection  from  direct  injury,  yet  a 
slight  injury  takes  more  effect  on  it  than  on  many  other  firmer 
organs,  and  we  have  experience  of  pancreatitis  resulting  from 
blows  in  the  epigastrium  apparently  trifling  in  character,  as  in  a 
case  that  I  saw  several  years  ago  where  a  butler  slipped  and  fell 
forward  against  a  knife-board  projecting  from  the  end  of  the 
table  at  which  he  was  working.  The  blow  was  comparatively 
slight,  and  the  man  did  not  even  fall  to  the  ground ;  but  acute, 
so-called  hemorrhagic  pancreatitis  followed,  and  the  patient 
died.  An  exploration  for  peritonitis,  followed  by  an  autopsy, 
revealed  the  true  cause  of  death. 

Probably  slight  injury  to  the  pancreas  often  occurs  in  abdom- 
inal operations  for  gallstones  in  the  common  duct,  when  it  is 
sometimes  necessary  to  manipulate  and  rather  forcibly  draw  the 
parts  in  the  neighborhood  of  the  pancreas  forward  in  order  to 
view  the  common  duct  when  sutures  are  applied. 

Such  a  case  has  indeed  been  related  recently. 

When  it  is  borne  in  mind  that  the  pancreatic  duct  opens  along 
with  the  common  bile  duct  into  the  second  part  of  the  duode- 
num, a  channel  usually  containing  septic  organisms,  especially 
when  it  is  the  seat  of  catarrh,  to  which  it  is  especially  liable,  it 


152  ROBSON, 

is  not  a  matter  for  surprise  that  pancreatitis  should  be  met  with, 
but  rather  that  it  should  not  occur  more  frequently. 

As  in  the  liver,  we  may  have  simple,  infective,  and  suppura- 
tive catarrh  of  the  excretory  ducts,  as  well  as  inflammation  of 
the  interlobular  tissues  ;  so  in  the  pancreas  we  undoubtedly  have 
similar  diseases,  which  are  only  awaiting  our  recognition  during 
life  by  greater  diagnostic  skill.  As  bearing  on  this,  the  pathol- 
ogist of  a  large  hospital  has  told  me  that  in  cases  of  obstruction 
of  the  common  duct  by  gallstones,  he  has  noticed  that  pus  can 
usually  be  expressed  from  Wirsung's  duct,  and  this  has  been 
confirmed  by  others. 

I  feel  sure  that,  as  our  means  of  diagnosis  become  more  per- 
fected, diseases  of  the  pancreas,  both  functional  and  organic, 
will  be  more  frequently  recognized  and  awarded  their  deserved 
positions  in  medicine. 

Since  my  countryman,  Dr.  Walker,  of  Peterborough,  showed 
that  the  absence  of  the  pancreatic  secretion  from  the  intestine, 
even  though  bile  were  present  in  the  intestinal  canal,  led  to  pale- 
colored  motions,  very  little  attention  has  been  paid  to  this  sign, 
although  much  has  been  written  about  the  presence  of  sugar  in 
the  urine  in  pancreatic  disease ;  yet,  glycosuria  is  in  my  expe- 
rience a  very  rare  phenomenon  in  this  relationship,  and,  in  fact, 
it  only  occurs  when  there  is  great  destruction  of  pancreatic 
tissues,  as  in  extensive  cirrhosis  or  in  extensive  malignant  dis- 
ease. 

Fat  in  the  stools  is  more  common,  but  not  by  any  means  uni- 
versal, and  lipuria  is  still  more  uncommon. 

I  have  seen  cases  of  discomfort,  with  some  swelling  at  the 
epigastrium,  associated  with  dyspepsia  and  ague-like  attacks, 
but  without  jaundice,  or  with  only  very  slight  jaundice,  which  I 
thought  might  be  explained  on  the  hypothesis  of  infective  in- 
flammation of  the  pancreatic  duct,  the  cases  having  cleared  up 
under  general  treatment.  I  have  also  seen  the  same  symptoms 
associated  with  more  pain,  irregular  fever,  more  marked  swelling 
and  tenderness  over  the  pancreas,  and  discharge  of  pus  by  the 
bowel  from  time  to  time,  but  without  any  collection  sufficiently 
large  to  form  a  distinct  abscess.     I  related  a  case  like  this  in 


ONPANCREATITIS.  153 

the  lecture  previously  referred  to,  but  the  recovery  of  the  patient 
made  the  absolute  certainty  of  the  diagnosis  doubtful,  though 
an  examination  under  an  anresthetic  enabled  a  swelling  of  the 
pancreas  to  be  felt,  and  this  was  confirmed  by  palpation  of  the 
abdomen  at  a  later  stage,  when  tenderness  was  less  marked. 

I  thought  this  case  was  probably  a  subacute  pancreatitis  as- 
sociated with  suppurative  catarrh  of  the  pancreatic  ducts  anal- 
ogous to  suppurative  cholangitis. 

The  essential  and  immediate  cause  of  the  various  forms  of 
pancreatitis  is  bacterial  infection,  this  having  been  positively 
proved  both  clinically  in  the  human  subject  and  experimentally 
in  the  lower  animals,  but  as  in  inflammatory  affections  of  the 
liver  and  bile  ducts  we  look  for  extrinsic  causes,  so  in  pancreatic 
diseases  we  find  biliary  and  pancreatic  lithiasis,  injury,  gastro- 
duodenal  catarrh,  ulcer,  and  cancer  of  the  stomach,  pylorus,  or 
duodenum,  and  zymotic  diseases,  such  as  typhoid  fever  and  in- 
fluenza, to  be  determining  factors,  though  in  some  cases  pancre- 
atitis has  come  on  suddenly  in  persons  in  robust  health  and  the 
determining  cause  has  been  beyond  recognition. 

Though  the  infection  may  arise  from  the  blood,  as  in  pyaemia, 
or  by  direct  extension  from  the  neighboring  tissues,  as  in  ulcer 
of  the  stomach,  yet  the  most  usual  channel  is  through  the  duct, 
as  in  the  cases  arising  from  gallstones  in  the  common  duct  and 
from  gastro-duodenal  catarrh  that  I  related  in  my  lecture. 

The  association  of  gallstones  with  chronic  pancreatitis  was 
absolutely  forced  on  my  mind  by  the  frequency  with  which  I 
found  inflammatory  enlargement  of  the  head  of  the  pancreas 
when  operating  for  gallstones  in  the  common  duct,  the  first 
instance  of  the  kind  having  been  observed  by  me  in  1892  in  a 
case  on  which  I  operated  for  deep  jaundice,  supposed  to  be  due 
to  common  bile-duct  obstruction,  but  in  which  I  found  cirrhosis 
of  the  head  of  the  pancreas.  Since  that  time  I  have  operated 
on  a  considerable  number  of  cases  (over  twenty),  and  though 
only  one  patient  has  died  directly  from  the  operation,  in  two 
others,  one  a  cholecystenterostomy  and  the  other  a  cholecystot- 
omy,  death  occurred  within  a  few  months,  and  the  correctness  of 
the  diagnosis  was  verified  both  by  autopsy  and  by  a  microscopical 


154  ROBSON, 

section  of  the  diseased  pancreas.  I  am  able  to  show  the  pan- 
creas from  the  last  case,  and  also  a  microscopical  section  of  the 
specimen.  It  is  a  simple  matter  to  infer  that  if  common  duct 
cholelithiasis  can  give  rise  to  chronic  pancreatitis,  it  will  also  be 
likely  to  induce  the  subacute  and  acute  form  of  the  disease,  and 
this  is,  I  think,  now  clearly  proved.  In  the  British  Medical 
Journal  for  November  14,  1896,  Dr.  Kennan  described  a  case 
of  acute  pancreatitis  ending  fatally  on  the  second  day  in  a 
woman,  aged  thirty-eight  years,  and  at  the  post-mortem  exam- 
ination a  large  number  of  gallstones  were  found  in  the  common 
duct,  one  being  partly  extruded  into  the  duodenum. 

Korte  {Deutsch  Chir.,  Stuttgart,  1898)  notes  that  lesions  of  the 
pancreas  are  frequently  associated  with  diseases  of  the  bile 
ducts. 

Lancereux  {Traite  des  maladies  des  foie  et  des  pancreas, 
1898)  mentions  the  possibility  that  a  gallstone  impacted  in 
the  diverticulum  of  Vater  may  occlude  the  pancreatic  duct  and 
produce  conditions  favoring  the  entrance  of  organisms  into  that 
duct. 

Dr.  Opie,  in  a  very  instructive  and  interesting  paper  in  the 
American  Journal  of  the  Medical  Sciences  for  January,  1901,  p. 
27,  relates  cases,  one  of  Dr.  Osier's  and  several  from  various 
sources,  showing  the  relationship  between  pancreatic  and  gall- 
stone troubles. 

Mr.  Gilbert  Barling  {British  Medical  jfoumal^  December  22, 
1900)  has  given  several  interesting  cases  bearing  out  very  fully 
the  views  expressed  above. 

In  some  of  my  cases  gallstones  were  not  found,  but  only  old 
and  firm  adhesions,  with  an  antecedent  history  of  paroxysmal 
attacks,  followed  by  jaundice,  which  afforded  strong  presump- 
tive evidence  that  cholelithiasis  had  been  present  at  some  time  ; 
and  it  seems  quite  possible  that  temporary  occlusion  of  the  com- 
mon duct  with  the  damming  back  of  infected  secretions,  or  with 
injury  to  the  ducts,  may  set  up  a  pancreatitis,  which  may  itself 
then  cause  compression  of  the  common  bile  duct,  and  so  lead  to 
a  perpetuation  of  the  obstructive  jaundice  and  other  troubles, 
started,  in  the  first  instance,  by  impacted  gallstones. 


ON    PANCREATITIS.  155 

Fat  Necrosis.  By  fat  necrosis  is  understood  a  splitting  up 
of  the  fat  into  fatty  acids  and  glycerin ;  the  latter  is  absorbed, 
but  the  acids,  being  insoluble,  remain  in  the  cells  and  unite  with 
calcium  salts,  forming  yellowish-white  patches  of  various  sizes 
in  the  subperitoneal  fat  and  in  the  omentum,  mesentery,  etc. 
It  was  first  described  by  Balser  in  1882,  but  has  been  since  in- 
vestigated by  Langehans,  Hildebrand,  Dettiner,  Milisch,  Wil- 
liams, Flexner,  Opie,  and  others.  Experiments  by  Opie,  who 
ligatured  the  pancreatic  ducts  in  the  cat,  go  to  show  that  wide- 
spread fat  necrosis  may  be  expected  to  follow  very  rapidly. 

Fat  necrosis  is  commonly  found  in  association  with  pancre- 
atitis and  other  diseases  of  the  pancreas,  and  the  relationship 
between  the  two  conditions  has  given  rise  to  much  speculation  ; 
but  the  facts  that  fat  necrosis  is  not  found  in  all  acute  pancre- 
atic diseases,  and  that  it  has  been  noted  during  abdominal  oper- 
ations for  other  ailments,  and  in  autopsies  where  there  was  no 
suspicion  of  pancreatitis,  appear  to  show  that  the  condition  giv- 
ing rise  to  it  is  not  essentially  a  pancreatitis,  as  suggested  by 
certain  authors ;  though  these  facts  do  not  disprove  that  fat 
necrosis  is  essentially  due  to  interference  with  the  discharge  of 
pancreatic  secretion,  and  so  to  an  escape  of  pancreatic  fluid  into 
the  tissues,  whence  it  may  be  taken  up  by  the  lymphatics  or 
bloodvessels.  Flexner  {Contribution  to  the  Science  of  Medicine, 
Johns  Hopkins  Press,  Baltimore,  1900)  and  others  regard  the 
fat  necrosis  as  the  effect  of  the  fat-splitting  ferment  of  the  pan- 
creatic fluid,  which  has  in  some  way  escaped  from  the  duct  into 
the  surrounding  tissues.  It  is  difficult  at  first  sight  to  explain 
the  patches  of  fat  necrosis  occurring  at  a  distance  from  the  pan- 
creas, for  instance,  in  the  pericardium,  unless  it  be  by  absorption 
of  the  ferment  and  its  diffusion  by  means  of  the  lymphatics; 
though  it  is  easy  to  understand,  and  it  undoubtedly  does  ex- 
plain the  disintegration  of  the  fatty  tissues  immediately  sur- 
rounding the  pancreas  and  extending  by  continuity,  first,  to 
adjoining  and  then  even  to  distant  parts  in  the  abdomen  and 
thorax. 

Hemorrhage  in  Pancreatic  Diseases.  It  is  well  known  that 
local  hemorrhages  into  the  pancreas  may  occur  apart  from  injury, 


156  ROBSON, 

and  apart  from  any  general  hemorrhagic  tendency,  and  that  al- 
though they  maybe  recovered  from,  as  shown  by  the  remains  of 
extravasated  blood  in  the  gland  in  persons  dying  from  other  dis- 
eases, yet  such  spontaneous  hemorrhages  may  lead  to  death  from 
collapse  either  immediately  or  after  some  hours.  Curiously,  this 
may  occur  in  persons  apparently  in  good  health  and  without  any 
premonitory  signs  on  which  a  diagnosis  can  be  based,  the  only 
symptoms  at  the  time  being  those  of  collapse,  with  dyspnoea 
and  feeble  pulse.  It  is  also  well  recognized  that  a  hemorrhagic 
condition  coexists  with  cancer  of  the  head  of  the  pancreas. 
Some  years  ago  I  thought  this  to  be  altogether  dependent  on 
the  cholsemia,  until  increased  experience  in  operations  on 
deeply  jaundiced  subjects  has  taught  me  that  there  is  much  less 
danger  of  serious  hemorrhage  in  patients  jaundiced  from  gall- 
stones than  in  those  where  the  jaundice  depends  on  pancreatic 
disease.  In  several  cases  of  cancer  of  the  pancreas  on  which  I 
have  operated,  the  bleeding  has  been  the  immediate  cause  of 
death.  In  one  aged  subject  especially  was  this  well  marked, 
after  a  cholecystotomy  for  the  relief  of  jaundice.  Death  oc- 
curred on  the  third  day  from  collapse,  and  at  the  autopsy  there 
was  found  extensive  effusion  of  blood  away  from  the  site  of 
operation  and  behind  the  peritoneum,  extending  into  the  loins 
around  the  kidneys,  and  into  the  cellular  tissue  beneath  the 
diaphragm,  the  blood  being  in  sufficient  quantity  to  account  for 
death ;  and  though  the  bleeding  had  evidently  arisen  from  the 
pancreas,  there  was  no  manifest  vascular  lesion  to  account  for 
the  hemorrhage.  In  another  case,  sent  to  me  in  1888  by  Pro- 
fessor Clifford  AUbutt,  a  cholecystotomy  was  followed  by  per- 
sistent oozing  of  blood  from  the  interior  of  the  gall-bladder  and 
from  the  stitch  punctures,  which  resisted  all  then  known  reme- 
dial measures  in  the  way  of  styptics,  pressure,  transfusion,  etc., 
and  proved  fatal  on  the  ninth  day.  In  neither  of  these  cases 
was  there  any  peritonitis  or  other  cause  than  the  hemorrhage  to 
account  for  death.  Now,  in  another  patient  equally  deeply 
jaundiced,  that  I  saw  with  my  colleague,  Dr.  Churton,  in  1889, 
but  where  the  disease  was  dependent  on  cancer  of  the  common 
bile  duct  above  the  entrance  of  the  pancreatic  duct,  there  was 


ONPANCREATITIS.  157 

no  hemorrhage,  although  the  patient  survived  several  weeks, 
and  died  from  exhaustion,  due  to  the  disease  and  to  the  suppu- 
rative cholangitis  accompanying  it.  I  could  give  many  similar 
comparisons,  showing  the  difference  between  the  behavior  of  the 
blood  in  the  two  classes  of  cases. 

Before  operating  on  these  cases,  I  now  always  administer 
chloride  of  calcium  in  30-  to  60-grain  doses,  thrice  daily,  for 
from  twenty-four  to  forty-eight  hours  previous  to  operation,  and 
by  enema  in  6o-grain  doses,  thrice  daily,  for  forty-eight  hours 
afterward.  This  is  nearly  always  successful  in  correcting  the 
hemorrhagic  tendency. 

The  following  case  illustrates,  as  well  as  any  case  could,  how 
the  failure  to  give  it  after  operation  led  to  hemorrhage,  and 
how  its  administration  in  heroic  doses  apparently  saved  the 
patient : 

Cholelithiasis;  deep  jaundice ;  chronic  pancreatitis ;  duodeno-chole- 
dochoiomy ;  hemorrhage;  recovery  (reported  by  Mr.  Gough,  Home 
Surgeon). — Mrs.  M.  E.  G.,  aged  thirty-eight  years,  was  admitted  to 
the  Leeds  General  Infirmary  on  January  23,  1901,  with  the  history 
that  she  had  had  typhoid  fever  in  September,  1899,  and  that  she  had 
never  been  quite  well  since.  Shortly  afterward  she  began  to  suffer 
from  biliary  colic,  though  she  had  never  been  jaundiced  till  six  months 
before  admission,  from  which  time  jaundice  had  never  left  her.  On 
December  24,  1900,  she  became  much  worse,  with  very  severe  parox- 
ysmal pain,  accompanied  by  shivering  and  profuse  sweats.  From  that 
time  she  lost  weight  very  rapidly,  and  the  jaundice  deepened.  On 
admission  the  liver  could  be  felt  below  the  ribs,  and  there  was  a  dis- 
tinct fulness  on  deep  palpation  in  the  region  of  the  pancreas. 

From  January  21st  to  the  31st  she  took  chloride  of  calcium  in 
20-grain  doses,  thrice  daily. 

January  31st  duodeno-choledochotomy  was  performed.  There  was 
very  little  bleeding.  A  stone,  nearly  as  large  as  a  pigeon's  egg,  was 
removed  from  the  ampulla  of  Vater,  which  was  laid  open  over  a  direc- 
tor introduced  through  the  papilla  at  its  opening  into  the  duodenum. 
The  head  of  the  pancreas  was  felt  to  be  much  enlarged  and  hard. 
The  incision  into  the  ampulla  was  not  sutured,  but  through  it  the 
common  bile  duct,  very  much  dilated,  was  explored  by  the  finger. 
The  anterior  wound  in  the  duodenum  was  then  sutured  and  the  ab- 


158  ROBSON, 

dominal  wound  closed.  A  drainage-tube  was  inserted  through  a  stab 
wound  in  the  right  loin.  The  patient  inadvertently  did  not  have 
chloride  of  calcium  given  in  the  nutrient  enemata,  as  is  usual  in  these 
cases.  She  did  well  till  the  morning  of  the  2d  of  February,  when 
the  nurse  noticed,  at  3  o'clock,  that  the  dressings  were  soaked  with 
bright  blood. 

The  drainage  wound  was  exposed,  but  no  hemorrhage  was  occurring 
there.  On  examining  the  abdominal  incision  blood  was  seen  to  be 
slowly  oozing  from  it  and  the  stitch  punctures.  One  drachm  of 
chloride  of  calcium  was  at  once  administered  by  the  mouth,  and  three 
stitches  were  removed.  The  surface  of  the  wound  was  then  seen  to 
be  oozing  all  over.  It  was  packed  with  gauze  soaked  in  tincture  of 
hamamelis,  and  a  firm  dressing  applied.  One  drachm  of  chloride 
of  calcium  was  given  again  in  two  hours,  and  afterward  repeated  in 
3ograin  doses  every  two  hours,  for  six  hours,  it  being  then  given 
thrice  daily.  There  was  no  recurrence  of  hemorrhage,  and  the  patient 
made  an  uninterrupted  recovery.  The  drainage-tube  was  removed  on 
February  4th,  and  she  returned  home  within  the  month. 

In  this  case  Mr.  Cammidge  found  the  characteristic  crystals 
in  the  urine,  and  an  examination  of  the  blood  showed  a  very 
marked  diminution  in  the  blood-plates. 

These  arguments  are  brought  forward  to  show  that  there  is 
some,  as  yet  ill  understood,  relation  between  pancreatic  disease 
and  serious  hemorrhage;  but  I  cannot  help  thinking  that  it  is  a 
mistake  to  allow  this  fact  to  influence  our  views  on  the  pathology 
of  inflammation  by  adopting  permanently  the  name  hemor- 
rhagic pancreatitis  in  cases  where  there  has  been  no  bleeding, 
or  no  more  than  occurs  frequently  in  inflammation  of  other 
parenchymatous  organs,  though  it  may  be  useful  to  retain  the 
name  for  those  cases  of  pancreatitis  associated  with  well-marked 
interstitial  hemorrhage,  and  in  which  the  disruption  of  the 
gland  by  the  bleeding  may  be  the  direct  cause  of  the  inflam- 
mation. 

I  have  recently  read  a  very  interesting  paper  in  the  Boston 
City  Hospital  Report  for  December,  1900,  by  Dr.  F.  B.  Lund, 
entitled  *'  Acute  Hemorrhagic  Pancreatitis  and  its  Surgical 
Treatment,  with  a  Report  of  Six  Cases,"  yet  in  remarking  on  the 


ON    PANCREATITIS.  159 

second  case,  the  author  says  :  "  This  case  is  notable  for  the 
absence  of  pancreatic  hemorrhage." 

In  the  fifth  case  there  was  the  evacuation  and  drainage  of  a 
small  abscess  of  the  pancreas,  and  no  evidence  of  hemorrhage, 
and  in  the  sixth  case  also  there  was  apparently  no  evidence 
whatever  of  hemorrhage.  The  title  of  the  paper  is  surely  a 
misnomer;  yet  other  authors  adopt  the  same  nomenclature  in 
the  same  indefinite  manner. 

Dr.  Flexner  produced  an  inflammation  of  the  pancreas  as- 
sociated with  hemorrhage,  within  forty-eight  hours,  by  inject- 
ing the  bacillus  pyocyaneus  and  the  B.  diphtherias  into  the 
pancreatic  duct  in  animals  {Coritributions  to  the  Science  of  Medi- 
cine, Baltimore,  igoo,  p.  743). 

Hlava  also  produced  hemorrhagic  pancreatitis  by  injecting 
the  B.  diphtheriae  into  the  pancreas. 

Hildebrand  {Centralbl.  filr  Chirurgie,  1894,  Band  xxii.  p.  297) 
suggested  that  the  hemorrhage  in  acute  pancreatitis  was  due  to 
trypsin. 

The  facts  concerning  hemorrhage  in  diseases  of  the  pancreas 
and  the  conclusions  we  have  come  to,  after  carefully  consider- 
ing the  whole  subject,  are  : 

I.  That  in  certain  diseases  of  the  pancreas  there  is  a  general 
hemorrhagic  tendency  which  is  much  intensified  by  the  pres- 
ence of  jaundice.  2.  That  hemorrhage  may  apparently  occur 
in  the  pancreas,  unassociated  with  inflammation,  or  with  jaun- 
dice, or  with  a  general  hemorrhagic  tendency.  3.  That  both 
acute  and  chronic  pancreatitis  can  and  do  frequently  occur  with- 
out hemorrhage.  4.  That  some  cases  of  pancreatitis  are  asso- 
ciated with  local  hemorrhage. 

From  these  conclusions  I  think,  therefore,  that  inflammations 
of  the  pancreas  may  be  more  conveniently  and  scientifically 
classified,  like  inflammation  of  other  organs,  as  acute,  subacute, 
and  chronic  ;  and  that  there  is  no  reason  to  use  the  term  hem- 
orrhagic pancreatitis,  except  as  a  variety  of  acute  pancreatitis, 
the  hemorrhage  being  merely  an  accident  in  the  course  of  the 
disease. 

It  seems  to  me  worth  while  considering  if  the  glycerin  set 


l60  ROBSON, 

free  in  the  tissues  by  the  fat  necrosis  may  possibly  be  the  real 
cause  of  the  local  hemorrhagic  tendency  in  pancreatic  affections, 
though  our  observations  are  not  yet  sufficiently  far  advanced  to 
say  that  this  is  an  adequate  explanation  of  all  the  cases. 

While  inquiring  into  the  subject  I  have  become  acquainted 
with  certain  very  important  facts  bearing  on  the  question.  If 
glycerin  in  very  small  amount  be  injected  into  mice  it  rapidly 
produces  haematuria  (Cammidge)  or  haemoglobinuria,  due  to 
destruction  of  the  blood-corpuscles,  and  in  certain  cases  in 
which  glycerin  has  been  used  by  gynecologists  for  the  purpose 
of  inducing  abortion,  and  in  others  where  it  has  been  injected 
along  with  iodoform  for  the  treatment  of  tubercular  disease  in 
the  human  subject,  blood  has  also  been  noticed  in  the  urine, 
sometimes  in  large  quantity. 

The  blood  conditions  about  to  be  mentioned  may  possibly  serve 
to  explain  the  general  hemorrhagic  tendency  in  cases  of  chronic 
pancreatitis  associated  with  jaundice  ;  but  behind  this  there  must 
be  some  other  cause  not  yet  discovered.  Can  it  be  due  to 
something  absorbed  from  the  pancreas  into  the  blood  which 
only  acts  when  the  absorption  has  been  occurring  over  a  pro- 
longed period  of  time?  This  matter  seems  to  me  to  be  worth 
attention,  and  it  should  be  possible  to  prove  or  disprove  it  by 
experimental  work. 

In  discussing  these  matters  with  Mr.  Cammidge,  he  suggested 
that  only  a  small  amount  of  glycerin  could  obtain  access  to  the 
blood  as  the  result  of  fat  necrosis.  When  the  glycerin  is  set 
free  and  the  fatty  acids  are  saponified  it  would  become  oxidized, 
just  like  any  other  alcohol,  and  the  oxidation  products  for  which 
one  would  look  would  be  an  aldehyde ;  but  the  tests  employed 
failed  to  demonstrate  this. 

In  the  course  of  these  investigations,  however,  it  was  found 
that  if  the  urine  were  boiled  for  a  short  time  with  an  oxidizing 
agent,  and  then  the  phenyl  hydrazin  test  performed,  an  abun- 
dant crop  of  delicate  yellow  needles  arranged  in  sheaves  and 
rosettes  was  produced  (specimen  shown). 

The  untreated  urine  gave  no  such  result.  Normal  urine, 
morbid   urines  from   gout,  etc.,  and,  most    important,  bilious 


ON    PANCREATITIS.  l6l 

urine  from  patients  suffering  from  simple  catarrhal  jaundice, 
also  gave  negative  results.  I  may  say,  also,  that  some  experi- 
ments performed  on  bile  and  bile  salts  yielded  none  of  the 
crystals. 

The  number  of  cases  is  too  few  to  allow  one  to  more  than 
suggest  that  it  may  prove  useful  as  a  diagnostic  test  in  this  class 
of  cases ;  but  it  is  also  interesting  to  note  that  on  one  day  I 
operated  on  two  patients  deeply  jaundiced,  in  one  of  which 
there  was  chronic  pancreatitis ;  whereas  in  the  other,  although 
there  was  a  small  gallstone  in  the  common  duct,  there  was  no 
manifest  enlargement  or  disturbance  of  the  pancreas.  Both 
urines  were  submitted  to  Mr.  Cammidge,  and,  without  his  know- 
ing the  history  of  either  case,  he  sent  me  word  that  the  urine  in 
the  latter  case  (where  there  was  no  pancreatitis)  gave  negative 
results,  so  far  as  the  crystals  were  concerned,  and  that  in  the 
former  case,  just  described  at  length,  he  was  able  to  obtain 
abundant  crystals. 

An  examination  of  the  blood  has  also  been  made  in  a  num- 
ber of  cases,  with  a  view  to  ascertain  if  any  information  can  be 
found  to  explain  the  hemorrhagic  tendency.  Although  glycerin 
may  be  present,  Mr.  Cammidge  knew  of  no  test  sufficiently  del- 
icate to  demonstrate  its  presence  in  the  blood. 

A  histological  examination  of  the  blood  showed,  in  two  of 
the  cases,  a  very  striking  diminution  in  the  number  of  blood- 
plates  as  compared  with  the  normal  blood.  This  diminution 
of  the  blood-plates,  whatever  may  be  its  cause,  may  possibly 
explain  the  general  hemorrhagic  tendency  in  these  cases. 

Treatment  of  Acute  Pancreatitis.  In  acute  infective  pan- 
creatitis treatment  practically  resolves  itself  into  that  of  peri- 
tonitis commencing  in  the  superior  abdominal  region.  The 
pain  at  the  onset  is  so  acute  as  to  necessitate  the  administration 
of  morphine,  and  the  collapse  will  probably  demand  stimulants, 
which,  on  account  of  the  associated  vomiting,  may  have  to  be 
given  by  enema.  In  the  early  stages  the  symptoms  are  usually 
so  indefinite  that  the  indications  for  surgical  treatment  are  not 
clear  enough  to  warrant  operation,  and  until  the  collapse  has 
passed  off  no  surgical  procedure  would  generally  be  justifiable. 

Am  Surg  ii 


l62  ROBSON, 

The  simulation  of  intestinal  obstruction  will  probably  lead  to 
efforts  to  secure  an  evacuation  of  the  bowels  and  relief  to  the 
distention. 

Just  as  in  a  perforative  or  gangrenous  appendicitis,  an  early 
evacuation  of  the  septic  matter  is  necessary  to  recovery,  so  in 
this  equally  lethal  affection  an  early  exploration  from  the  front, 
through  the  middle  line  above  the  umbilicus,  or  from  behind 
through  the  left  costo-vertebral  angle,  is  demanded,  in  order  to 
evacuate  the  septic  material  and  adopt  free  drainage. 

The  after-treatment  will  be  chiefly  directed  to  combating 
shock  and  keeping  up  the  strength  until  the  materies  morbi, 
both  local  and  general,  can  be  thrown  off. 

Even  if  no  pus  be  founds  no  harm  should  accrue  by  such  an 
exploration,  which  can  be  made  in  a  few  minutes  through  a 
very  small  incision  in  the  middle  line  above  the  umbilicus,  if 
necessary,  with  the  aid  of  cocaine  anaesthesia.  After  establish- 
ing the  diagnosis  by  the  anterior  small  incision  and  the  intro- 
duction of  a  finger,  the  posterior  incision,  which  must  be  a  free 
vertical  one  in  the  left  costo-vertebral  angle,  so  as  to  permit  the 
insertion  of  the  whole  hand,  if  thought  necessary,  will  enable 
the  diseased  organ  to  be  very  freely  examined,  and,  if  neces- 
sary, drained  for  the  evacuation  of  pus  and  gangrenous  material, 
thus  involving  no  risk  to  the  general  peritoneal  cavity  and  little 
danger  of  retained  septic  matter,  as  the  drainage  will  be  a  de- 
pendent one. 

Treatment  of  Subacute  Pancreatitis.  The  subacute  form 
of  pancreatitis  is  more  amenable  to  treatment,  as  the  indications 
are  so  much  more  definite,  and  there  is  more  time  for  careful 
consideration ;  and  though  it  has  usually  only  been  attacked 
when  an  abscess  has  formed  and  is  manifestly  making  its  way 
to  the  surface,  yet  there  is  no  reason  why  in  some  cases  surgi- 
cal treatment  should  not  be  adopted  at  an  earlier  stage.  As  in 
the  acute  condition,  morphine  may  be  required  to  relieve  the 
collapse  and  support  the  strength. 

Distention,  if  present,  may  also  demand  attention,  and  may 
have  to  be  relieved  by  lavage  of  the  stomach  and  turpentine 
enemata  or  by  the  administration   of  calomel   by  the   mouth. 


ON     PANCREATITIS.  163 

Calomel  is  also  of  benefit  by  acting  as  an  intestinal  antiseptic; 
for  which  purpose  it  may  be  given  in  small  repeated  doses  or 
in  doses  of  five  grains,  followed  by  a  saline  aperient.  As  soon 
as  the  constipation  is  relieved,  diarrhcea  is  apt  to  supervene, 
when  salol  and  bismuth,  with  small  doses  of  opium,  may  be 
given. 

If  surgical  treatment  is  decided  on,  a  median  incision  above 
the  umbilicus  will  enable  the  operator  to  palpate  the  pancreas 
and  locate  any  incipient  collection  of  pus,  which,  if  practi- 
cable, should  then  be  evacuated  by  a  posterior  incision  in  the 
left  or  right  costo-vertebral  angle;  or  if  the  posterior  incision  be 
thought  impracticable,  the  collection  of  pus  may  be  aspirated  and 
the  cavity  opened  and  packed  with  gauze,  which  may  be  brought 
forward  through  a  large  rubber  drainage-tube,  which  will,  in  the 
course  of  from  twenty-four  to  forty-eight  hours,  establish  a 
track  isolated  from  the  general  peritoneal  cavity.  In  one  case 
I  was  able  to  do  this,  but  the  operation  was  undertaken  at  too 
late  a  stage  to  be  successful,  and  though  the  patient  lived  two 
or  three  days  afterward,  the  evacuation  of  the  pus  seemed  to 
make  very  little  difference  to  the  general  septic  condition  pre- 
viously existing,  and  death  occurred  on  the  fourth  day  from 
increasing  debility. 

The  method  adopted  had,  however,  been  successful  from  the 
point  of  view  of  drainage,  and  the  track  of  the  gauze  and  tube 
had  been  isolated  from  the  general  peritoneal  cavity.  If  a  defi- 
nite abscess  form  and  approach  the  surface  in  front  or  in  either 
loin,  the  treatment  will  be  that  of  incision  and  drainage,  as  in 
the  case  of  any  other  abdominal  abscess.  Of  five  cases  on 
which  I  have  operated,  three  recovered  completely,  one  recov- 
ered from  the  operation,  but  died  a  few  weeks  later  from  chest 
complications  and  debility,  and  the  fifth  case  is  the  one  just 
referred  to. 

The  strength  must  be  maintained  by  careful  feeding  and  the 
administration  of  stimulants,  and  it  will  be  necessary  to  keep  a 
sharp  lookout  for  further  collections  of  pus  and  for  subphrenic 
abscess  or  empyema,  which,  on  recognition,  will  need  treat- 
ment. 


1 64  R  O  B  S  O  N , 

The  following  case  of  pancreatitis  is  so  exceptional,  both  with 
regard  to  course  and  treatment,  that  I  think  it  is  worth  relating : 

Chronic  gastric  ulcer  eroding  pancreas.  Pancreatitis.  Abscess  of 
pancreas  bursting  into  stomach.  Vomiting.  Impending  death.  Pos- 
terior gastro-enterostomy.  Recovery. — On  November  12,  1900,  I  was 
asked  by  Dr.  Mercer,  of  Bradford,  to  see  Mr.  R.,  who  was  extremely 
ill  and  supposed  to  be  suffering  from  pancreatic  disease. 

On  arrival  I  found  the  patient,  aged  thirty-five  years,  extremely 
emaciated,  lying  in  a  typhoid  condition,  vomiting  extremely  offensive 
dark-colored  pus  and  mucus  mixed  with  blood.  He  was  extremely 
feeble  and  had  a  rapid,  weak  pulse  and  a  slight  icteric  tinge  in  the 
conjunctivae ;  a  tumor  could  be  felt  above  the  umbilicus,  which  was 
tender  to  pressure.  On  distending  the  stomach  with  COj  great  pain 
was  produced,  and  vomiting  followed.  The  stomach  was  dilated, 
reaching  on  the  left  side  to  the  level  of  the  umbilicus. 

There  had  been  an  elevated  temperature  for  a  few  weeks,  but  this 
had  become  subnormal  after  the  vomiting  of  pus.  Pain  after  food 
and  indigestion  had  existed  for  some  months,  during  which  time  there 
had  been  steady  loss  of  flesh  :  but  recently,  especially  during  the 
last  month,  the  wasting  had  been  very  considerable.  There  was  a 
little  sugar  in  the  urine,  with  a  trace  of  albumin,  and  the  feces  con- 
tained free  fat. 

No  medicine  had  done  any  good  either  for  the  relief  of  the  vomit- 
ing or  in  controlling  the  horrible  odor,  which  permeated  the  whole 
house.  A  diagnosis  of  chronic  gastric  iilcer  of  the  posterior  wall  of 
the  stomach,  with  secondary  ulcerative  pancreatitis  and  a"bscess  of  the 
pancreas,  was  made,  and  gastro-enterostomy  proposed  as  the  only 
means  likely  to  produce  any  chance  of  relief,  but  even  that  seemed 
almost  hopeless. 

He  was  removed  to  a  surgical  home  by  ambulance,  and  the  stomach 
was  washed  out  carefully  by  Dr.  Stevens.  As  showing  the  nature 
of  the  stomach  contents,  both  of  the  attendant  nurses  were  made  sick 
by  the  odor  of  the  material  evacuated  by  the  tube. 

On  November  i8th,  after  enveloping  the  patient  in  cotton-wool 
and  subcutaneously  administering  strychnine,  posterior  gastro-enter- 
ostomy was  performed,  a  bone  bobbin  being  used.  The  operation  was 
done  as  quickly  as  possible  in  order  to  save  shock.  The  tumor 
felt  before  operation  was  found  to  be  formed  by  stomach  and  pan- 
creas firmly  fixed  together  toward  the  pyloric  end,  but  leaving  the 


ON    PANCREATITIS.  165 

dilated  portion  free  at  the  cardiac  end  of  the  stomach,  so  that  no 
difficulty  was  found  in  doing  a  satisfactory  operation,  which  was  com- 
pleted in  twenty  minutes.  Saline  subcutaneous  injections  and  rectal 
injections  were  given,  and  strychnine  was  freely  administered,  but  for 
two  days  we  had  a  great  fight  with  death,  apparently  due  to  poisoning 
with  the  foul  stomach  contents.  Hot  water  was  freely  given  to  induce 
vomiting  on  the  second  day,  as  the  patient  could  not  bear  the  stomach- 
ptube  being  used.  This  gave  relief,  and  afterward  progress  to  recovery 
was  uninterrupted.  He  rapidly  gained  strength  and  put  on  flesh,  re- 
turning home  five  weeks  after  operation.  His  friends,  who  had 
despaired  of  his  recovery,  were  astonished  to  find  him  so  well.  In 
April  he  was  in  such  good  health  that  he  married. 

The  treatment  of  chronic  pancreatitis  is  also  by  abdominal 
section  and  drainage,  but  in  this  case  the  drainage  is  indirect 
and  obtained  by  draining  the  gall-bladder  by  cholecystotomy, 
cholecystenterostomy,  or  duodeno-choledochotoniy.  The  exact 
line  of  treatment  cannot  be  determined  until  the  abdomen  is 
opened,  and  for  this  purpose  I  prefer,  as  in  all  my  gall-bladder 
operations,  a  vertical  incision  through  the  upper  part  of  the 
right  rectus,  splitting  that  muscle  to  whatever  extent  is  neces- 
sary in  order  to  obtain  a  good  view  of  the  diseased  region  and 
to  afford  plenty  of  room  for  manipulation. 

If  a  mere  cholecystotomy  on  a  distended  gall-bladder  is  neces- 
sary, an  incision  of  one  or  two  inches  will  usually  suflfice,  but  if 
the  gall-bladder  be  contracted,  or  if  the  ducts  have  to  be  attacked, 
an  incision  of  four  to  six  inches  will  be  required,  and  if  the  sev- 
eral layers  of  the  abdominal  wall  are  sutured  separately  there  is 
no  fear  of  subsequent  hernia.  This  I  can  affirm  by  ample  expe- 
rience. It  saves  much  time  and  much  unnecessary  dragging  on 
the  parts  when  operating  on  the  common  duct  or  duodenum  to 
have  a  free  incision,  and  there  is  no  retractor  equal  to  the  hand 
of  a  skilful  assistant,  who,  with  a  flat  sponge  interposed  between 
the  spread-out  fingers  of  his  left  hand  and  the  viscera,  will  at 
the  same  time  afford  the  operator  a  good  view  of  the  field  of 
operation,  and  with  his  right  hand  help  in  the  further  steps  of 
the  operation. 

If  the  right  costal  margin  or  the  edge  of  the  liver  be  obstruct- 


l66  ROBSON, 

ing  the  view,  another  assistant  may  with  advantage  retract  it 
either  by  digital  manipulation  or  by  means  of  a  wide  retractor 
with  a  long  handle,  so  that  he  can  stand  back  a  little  and  avoid 
embarrassing  the  operator.  As  a  matter  of  experience,  I  sel- 
dom find  a  second  assistant  necessary.  A  sponge  in  the  pouch 
to  the  right  of  the  common  duct,  and  one  pushed  down  over  the 
right  kidney,  helps  to  catch  all  escaping  fluids  and  to  keep  the 
peritoneum  clean.  When  the  ducts  or  the  duodenum  are  opened, 
sterilized  gauze  pads  are  employed  to  mop  up  the  fluid  as  it 
escapes,  but  none  of  these  is  allowed  to  remain  even  tempo- 
rarily in  the  abdomen.  When  there  are  gallstones  present  they 
should  be  removed,  unless  the  patient  is  too  ill  to  permit  of  the 
complete  operation  ;  but  in  every  case  drainage  must  be  secured, 
if  possible  by  cholecystotomy  as  in  nearly  all  my  successful  cases  ; 
moreover,  the  drainage  must  not  be  stopped  before  the  bile 
has  become  healthy,  and  not  before  the  greater  amount  of  bile 
is  being  passed  by  the  bowel,  which  will  be  certain  to  occur  as 
soon  as  the  swollen  pancreas  has  subsided,  if  the  duct  be  other- 
wise clear  of  obstruction. 

It  might  be  thought  that  cholecystenterostomy  would  be  an 
ideal  operation  in  the  treatment  of  these  cases,  but  experience 
says  it  is  not ;  for  instance,  in  one  of  my  cases  the  operation 
brought  about  so  much  relief  that  a  cure  was  being  anticipated, 
yet  in  the  third  month  relapse  occurred,  and  death  ensued  ap- 
parently simply  owing  to  closure  of  the  new  opening  between 
the  gall-bladder  and  duodenum. 

In  one  of  Mr.  Barling's  cases  {^British  Medical  Journal,  Decem- 
ber 22,  1900),  where  the  gall-bladder  was  joined  to  the  duode- 
num, he  states  that,  although  the  symptoms  were  relieved, 
enlargement  of  the  pancreas  persisted. 

The  course  and  treatment  of  chronic  interstitial  pancreatitis 
are  exemplified  in  the  cases  related  in  my  lecture  before  the  Poly- 
clinic in  June  of  last  year.  Possibly  in  some  of  these  the 
manipulation  of  the  indurated  tumor  may  have  detached  calculi 
impacted  in  the  pancreatic  duct,  though  I  was  unconscious  of  it ; 
but  in  others,  the  relief  of  tension  as  the  result  of  draining  the 
bile    ducts    by   cholecystotomy  or    cholecystenterostomy  indi- 


ON    PANCREATITIS.  167 

rectly  drained  the  pancreatic  duct,  and  thus  led  to  a  subsidence 
of  the  pancreatitis,  then  to  an  opening  of  the  common  duct  by 
the  relief  of  the  tension,  and  so  to  a  cure  of  the  patient.  The 
simulation  of  malignant  disease  of  the  head  of  the  pancreas 
by  chronic  interstitial  pancreatitis  would  make  me  hesitate  to 
decline  operation  in  any  case  of  distended  gall-bladder  where 
the  patient  is  in  a  condition  to  bear  it,  or  even  in  any  case  of 
chronic  jaundice  without  distention  of  the  gall-bladder,  where 
the  general  health  is  deteriorating,  as,  though  it  should  be  rec- 
ognized that  if  the  disease  be  really  malignant,  very  little  good 
will  be  done,  and  life  may  even  be  shortened  or  only  prolonged 
for  a  short  time,  yet  if  the  disease  prove  to  be  chronic  pancre- 
atitis, a  real  and  permanent  cure  may  be  brought  about.  If  a 
calculus  be  felt  embedded  in  the  head  of  the  pancreas  or  im- 
pacted in  the  pancreatic  duct,  it  may  be  reached  through  the 
second  part  of  the  duodenum  by  laying  open  the  papilla  and 
exploring  the  duct,  or  by  dividing  the  peritoneum,  passing  be- 
tween the  duodenum  and  hepatic  flexure  of  the  colon,  and  then 
cutting  through  the  overlying  pancreas  on  to  the  concretion. 
If  the  papilla  common  to  the  bile  and  pancreatic  ducts  be  in- 
cised in  the  duodenum,  it  does  not  require  suture,  and  in  the 
cases  in  which  I  have  explored  the  ducts  by  the  duodenal  route 
there  has  been  no  serious  hemorrhage ;  the  anterior  duodenal 
opening  only  requires  closing  by  a  mucous  and  a  serous  suture. 
Drainage  of  the  right  kidney  pouch  for  from  twenty-four  to 
forty-eight  hours  is  advisable,  though  not  always  necessary,  and 
this  is  best  done  by  a  stab  wound  at  the  most  dependent  part. 

The  result  of  treatment  in  this  class  of  cases  has  been  most 
encouraging,  as  out  of  twenty-two  cases  operated  on  only  one 
died  directly  from  operation,  and  in  that  case  the  patient's  life 
was  only  very  slightly  shortened,  since  he  was  reduced  to  the 
last  stage  of  exhaustion  before  a  surgical  operation  was  sought. 
Of  those  recovering  from  operation,  with  the  exception  of  two 
who  died  a  few  months  later,  complete  and  perfect  recovery  en- 
sued. These  results  contrast  very  markedly  with  the  surgical 
treatment  of  cancer  of  the  pancreas,  where  nearly  half  the  cases 
operated  on  have  died  directly  as  the  result  of  operation,  and  in 


l68  ROB  SON, 

those  who  have  survived  life  has  only  been  prolonged  for  a  com- 
paratively short  time. 

Of  the  three  following  cases,  two  have  not  been  previously 
reported : 

Chronic  pancreatitis.  Cholecystotomy.  Cure.  Mr.  D.,  aged  forty- 
five  years,  was  brought  to  see  me  March  3,  1898,  the  history  being 
that  he  had  been  well  up  to  twelve  months  before,  when  he  began  to 
have  painful  attacks  at  the  pit  of  the  stomach,  ending  in  vomiting,  but 
not  followed  by  jaundice  until  an  attack  on  January  i,  1S98,  since 
which  time  he  had  been  deeply  and  continuously  jaundiced.  He  had 
also  from  that  time  onward  had  continued  ague-like  attacks,  and  two 
days  before  seeing  me  he  had  had  within  twenty-four  hours  three  of  these 
seizures,  each  accompanied  by  pain.  Within  a  twelvemonth  he  had 
lost  2  stone  8  pounds  in  weight.  On  examining  him  there  was  some 
swelling  in  the  gall-bladder  region,  but  no  tenderness.  The  liver  was 
a  little  enlarged,  but  the  margins  felt  smooth.  There  was  decided 
tenderness  in  the  middle  line  just  above  the  umbilicus,  and  on 
deep  pressure  the  pain  was  considerable  and  an  indefinite  fulness 
could  be  felt.  The  diagnosis  of  gallstones  in  the  common  duct 
was  made  and  an  operation  was  advised.  The  patient  was  oper- 
ated on  at  a  surgical  home  on  March  30th,  when  the  gall- 
bladder was  found  to  be  slightly  distended  and  surrounded  by  adhe- 
sions to  the  pylorus,  duodenum,  colon,  and  omentum.  No  gall- 
stones could  be  discovered,  but  there  was  a  well-marked  swelling  of 
the  head  and  the  first  two  inches  of  the  pancreas,  which,  though 
nodular  and  irregular,  was  not  very  hard.  This  extended  further  to 
the  right  than  normal,  so  as  to  cover  in  the  lower  end  of  the  common 
bile  duct.  Cholecystotomy  was  performed.  Within  twenty-four  hours 
of  the  operation  nearly  four  pints  of  very  off'ensive  bile  were  dis- 
charged through  the  tube.  A  specimen  was  examined  by  the  Clinical 
Research  Association,  and  their  report  was  as  follows:  "The  bile 
contains  both  staphylococci  and  streptococci,  but  no  bacillus  coli 
communis  could  be  found  either  under  the  microscope  or  in  the  cul- 
ture." Fearing  that  the  disease  might  be  malignant,  and  the  patient 
being  so  extremely  weak  and  ill,  I  gave  a  poor  prognosis,  but  in  a 
few  days  I  was  able  to  write:  "The  patient  is  progressing  very 
satisfactorily,  though  he  is  still  profoundly  weak.  Bile  has  appeared 
in  the  motions,  so  that  the  obstruction  is  evidently  overcome.  The 
bowels  have  been  moved  naturally,  and  the  patient  is   less  deeply 


J 


ON     PANCREATITIS.  169 

jaundiced  and  looking  better  generally."  On  April  5th  I  was 
able  to  report  that  he  was  taking  food  well  and  that  bile  was  passing 
freely  in  the  motions.  He  had  had  no  recurrence  of  the  shivering 
attacks.  The  drainage  was  continued  for  fourteen  days.  On  the 
20th  he  returned  home.  The  urine  was  then  free  from  bile,  and  the 
motions  were  assuming  a  natural  color ;  he  was  taking  food  well, 
gaining  flesh,  and  looking  better  generally.  I  still,  however,  gave  a 
guarded  prognosis,  though  I  said  that  I  hoped  that  the  tumor  would 
prove  to  be  inflammatory  and  not  malignant. .  From  that  time  onward 
his  progress  to  recovery  was  extremely  rapid.  A  report  I  had  of  his 
condition  a  few  months  later  said  he  was  perfectly  well  in  every 
respect  and  that  he  had  fully  regained  his  lost  weight. 

On  March  28th  of  this  year  I  had  a  letter  from  Mr.  D.  on  the  third 
anniversary  of  his  operation,  expressing  his  gratitude  and  saying  he 
was  in  perfect  health. 

Chronic  pancreatitis,  with  abscess  associated  with  gallstones.  Chole- 
cystotomy  ;  relief.  Death  four  months  later  from  exhaustion.  Autopsy. 
Mr.  H.,  aged  forty  years,  seen  by  me  with  Dr.  Woods,  of  Batley, 
on  October  11,  1900.  The  patient  was  then  deeply  jaundiced  and 
extremely  ill,  suffering  from  continuous  fever  with  exacerbations,  great 
debility,  and  extreme  emaciation.  A  large  tumor  in  the  region  of  the 
pancreas  could  then  be  felt  as  well  as  a  distended  gall-bladder.  He 
gave  the  history  of  failing  health  for  nine  months  and  a  history  of 
gallstone  attacks  and  painful  indigestion  for  some  time  before  that ; 
but,  although  he  had  had  frequent  attacks  of  abdominal  pain  for  three 
or  four  months,  the  jaundice  had  only  supervened  a  fortnight  before 
my  seeing  him.  At  the  operation  he  was  too  ill  to  bear  a  prolonged 
search,  and  there  were  numerous  adhesions  around  the  tumor,  which 
was  made  out  to  be  a  swelling  of  the  pancreas ;  the  gall-bladder  was 
simply  opened  and  drained  of  a  quantity  of  muco-pus.  A  quantity 
of  pus  was  discharged  from  the  drainage-tube  several  da)s  after  opera- 
tion, and  this  was  repeated  on  two  or  three  occasions,  as  if  it  came 
from  a  deeply-seated  abscess.  A  large  drainage-tube  having  been 
used,  there  was  a  free  discharge  of  bile  and  a  considerable  number  of 
gallstones  were  evacuated  through  it,  thirty-three  in  all.  Previous  to 
the  operation  the  patient  was  suffering  from  shivering  attacks  and  a 
persistently  elevated  temperature,  which  subsided  immediately  after 
drainage  was  eff"ected,  and  the  temperature  kept  nearly  normal  through- 
out the  remainder  of  his  illness,  it  being  normal   in  the  morning. 


170  ROB  SON 


though  there  was  usually  a  hectic  rise  each  evening.  He  made  a  slow 
though  apparently  steady  recovery  from  the  operation,  and  the  pan- 
creatic tumof  diminished  so  rapidly  that  it  was  confidently  believed 
to  be  entirely  disappearing,  it  being  only  one-third  as  large  as  at  the 
time  of  the  operation.  He  returned  home  December  14th,  but  he 
never  really  picked  up  strength,  and,  though  there  was  no  further  ele- 
vation of  temperature,  he  gradually  got  weaker  and  died  in  February. 

At  the  post-mortem  examination  made  by  Dr.  Woods  a  tumor  of 
the  pancreas  was  discovered,  which  was  carefully  examined  by  Mr. 
Cammidge  and  pronounced  to  be  a  chronic  inflammatory  tumor,  and 
not  new  growth,  the  centre  being  occupied  by  pulpy  material  where 
the  abscess  had  originally  been.  Nothing  else  was  discovered,  and 
there  were  no  gallstones  left,  either  in  the  gall-bladder  or  ducts.  I 
am  able  to  show  you  the  specimen  and  also  a  microscopic  section,  for 
the  preparation  of  both  of  which  I  have  to  thank  Mr.  Cammidge. 

Chronic  Pancreatitis.  Chole cystotomy.  On  the  28th  of  January, 
1901,  Mr.  E.  R.  H.,  aged  twenty-six  years,  was  sent  to  me  from  Mal- 
vern. He  was  deeply  jaundiced,  and  told  me  that  he  had  had  jaun- 
dice since  the  age  of  seventeen,  it  having  supervened  upon  a  severe 
attack  of  what  appeared  to  be  biliary  colic,  he  having  had  several 
seizures  since  the  age  of  fourteen.  For  two  or  three  years  he  had 
had  severe  ague-like  seizures,  and  during  that  time  lost  very  seriously 
in  weight  and  strength,  but  during  the  last  two  years  there  had  been 
no  shivers,  and  also  he  had  been  free  from  the  severe  paroxysms  of 
pain,  though  he  had  had  slighter  seizures,  after  all  of  which  the  jaun- 
dice became  more  intense.  The  patient  was  then  only  weighing  nine 
stone,  and  all  the  bile  was  apparently  passing  in  the  urine  and 
none  in  the  motions.  There  was  also  some  swelling  in  the  region 
of  the  pancreas,  slight  enlargement  of  the  liver,  and  a  very  decided 
enlargement  of  the  spleen. 

Four  days  later  the  abdomen  was  opened  by  a  vertical  incision 
through  the  right  rectus.  The  gall-bladder  was  found  contracted  and 
surrounded  by  numerous  adhesions.  After  the  separation  of  these 
the  ducts  were  carefully  explored,  but  without  discovering  any  gall- 
stones. The  head  of  the  pancreas  was  found  to  be  enlarged  and  very 
hard.  As  the  obstruction  appeared  to  be  entirely  due  to  the  pressure 
exercised  by  the  pancreas  on  the  common  duct,  the  gall-bladder  was 
drained.  For  a  few  days  the  jaundice  was  deeper.  It  then  became 
gradually  less  until   it  almost   disappeared.     In  ten  days  the  stools 


ON    PANCREATITIS.  I7I 

became  bile-stained  and  have  since  retained  their  color,  though  there 
has  never  been  complete  freedom  from  a  tinge  of  jaundice  to  the 
skin.  He  returned  home  on  the  i6th  of  April,  having  gained  nearly 
half  a  stone  in  weight.  He  looked  and  felt  much  better,  and  as  a 
email  quantity  of  bile  was  still  coming  from  the  tube,  it  seemed  desira- 
ble to  retain  it  until  the  last  tinge  of  jaundice  had  disappeared.  From 
the  first  week  of  operation  up  to  the  present  he  has  had  no  further 
pain,  and  has  been  able  to  take  ordinary  food  and  digest  it  well. 


172  DISCUSSION. 


DISCUSSION. 

Dr.  George  E.  Brewer,  of  New  York. 

After  listening  to  the  able  and  instructive  paper  which  our  distin- 
guished guest  has  just  presented  to  us  upon  the  subject  of  pancreatitis, 
I  must  confess  that  it  is  with  a  very  considerable  feeling  of  diffidence, 
and  with  no  small  measure  of  hesitation,  that  I  rise  to  open  the  discus- 
sion of  a  subject  in  which  my  personal  experience  has  been  so  limited. 
I  feel,  however,  that  I  can  at  least  offer  the  reader  of  the  paper  the 
sincere  thanks  of  the  Association  and  assure  him  of  our  appreciation 
of  the  courtesy  he  has  shown  us  in  coming  this  great  distance  to  pre- 
sent before  the  American  Surgical  Association  the  results  of  his  accu- 
mulated experience  in  this  important  surgical  disease.  That  it  is  an 
important  surgical  affection  cannot  for  a  moment  be  questioned  when 
we  consider  the  constantly  increasing  mass  of  evidence  which  is  being 
furnished  us  from  the  autopsy-table  of  its  serious  nature,  its  frightful 
mortality,  and  its  obscure  symptomatology.  That  the  disease  is  of  far 
more  frequent  occurrence  than  is  generally  supposed  is  evidenced  by 
the  fact  that  certain  pioneers,  like  the  writer  of  the  paper,  have  had 
such  a  large  personal  experience,  and  also  by  the  fact  that  in  certain 
medical  centres  where  the  disease  has  been  discussed  extensively  a 
fairly  large  number  of  cases  are  annually  reported.  That  it  is  not  gen- 
erally recognized  by  the  profession  at  large  is  evidenced  by  the  fact 
that  in  other  localities  no  reports  of  cases  are  presented. 

In  looking  over  some  fifteen  or  twenty  of  the  more  recent  annual 
reports  of  a  number  of  New  York's  largest  hospitals,  I  find  but  one  in 
which  the  disease  is  spoken  of  as  having  been  treated  surgically.  In 
this  single  exception  four  cases  are  reported  to  have  been  operated 
upon  during  one  year.  The  reason  of  this  failure  to  recognize  this 
disease  is  twofold,  the  first  being  that  the  attention  of  the  profes- 
sion has  not  been  directed  to  it  by  the  reports  of  cases  and  mono- 
graphs on  the  subject,  and  the  other  is  that  sufficient  data  have  not 
been  collected  to  enable  us  to  present  an  accurate  or  complete  cata- 
logue of  characteristic  symptoms.  As  in  the  case  of  the  pelvic  inflam- 
mations, of  appendicitis,  or  inflammatory  diseases  of  the  biliary  pas- 
sages, and  more  recently  in  the  perforative  lesions  of  the  stomach  and 
duodenum,  many  years  elapsed  after  the  earlier  recorded  cases  before 
the  symptomatology  of  these  conditions  was  generally  recognized  by 


ON    PANCREATITIS.  173 

the  medical  profession.  It  seems  to  me,  therefore,  that  it  is  important 
for  us  as  surgeons  to  be  constantly  on  the  watch  for  this  disease,  and 
to  accurately  record  and  publish  the  clinical  histories,  results  of  opera- 
tion, and  autopsy  findings  of  all  cases  of  this  fatal  disorder  which  come 
under  our  observation.  This  should  be  done,  not  only  with  a  view  to 
calling  the  attention  of  the  general  medical  public  to  the  disease,  but 
also  with  a  view  to  collecting  data  which  by  a  later  analysis  may  enable 
us  to  get  a  more  accurate  idea  of  its  pathology,  clinical  history,  and 
general  behavior. 

But  it  is  not  my  intention,  Mr.  President,  to  dwell  on  the  clinical 
side  of  the  case,  for  there  are  those  here  whose  experience  entitles 
them  to  speak  with  far  more  authority.  It  has  occurred  to  me  that  in 
considering  this  question  from  a  surgical  point  of  view  a  review  of  the 
anatomy  of  this  region  might  be  of  interest,  not  only  in  explaining 
some  points  in  the  clinical  history  of  the  disease  and  pathology,  but 
it  also  might  furnish  some  suggestions  regarding  treatment.  It  will  be 
remembered  that  at  a  very  early  period  in  the  development  of  the  em- 
bryo the  pancreas  is  formed  by  two  offshoots  from  the  intestinal  tube, 
just  below  the  gastric  dilatation  between  the  two  layers  of  the  poste- 
rior mesentery.  These  two  buds  rapidly  develop  backward,  giving  off 
numerous  branches,  which  again  divide  and  subdivide,  forming  an  in- 
numerable number  of  fine  twigs,  each  one  ending  in  a  small  epithelial- 
lined  sac.  These  are  surrounded  by  minute  plexuses  of  bloodvessels, 
nerves,  and  lymphatics,  and  held  together  by  areolar  tissue,  which,  by 
its  distribution,  divides  the  gland  into  a  large  number  of  segments  or 
lobules.  The  bud  nearest  the  pylorus  grows  in  this  manner  much 
more  rapidly  than  the  one  lower  down,  and  soon  forms  the  major  part 
of  the  gland.  A  few  weeks  later  this  fuses  with  the  inferior  gland,  and 
from  that  time  on  the  two  develop  as  a  single  structure.  At  a  very 
early  period  another  outgrowth  from  the  duodenal  mucous  membrane 
occurs,  which  projects  between  the  two  layers  of  the  anterior  mesen- 
tery. This  afterward  forms,  by  its  development,  the  liver.  The  bile 
duct,  at  first  separate  from  the  two  pancreatic  ducts,  later  fuses  with  the 
lower  duct,  the  two  forming  the  ampulla  of  Vater,  which  opens  into 
the  duodenum,  as  in  the  adult  subject.  A  number  of  variations  are 
found  in  the  adult  human  subject.  The  older  anatomists  taught  that 
the  upper  pancreatic  duct  gradually  atrophied  and  only  remained  patent 
in  a  few  instances.  Later  investigation  by  improved  methods  shows 
conclusively  that  the  duct  of  Santorini  is  practically  always  present  in 
the  human  subject. 


174  DISCUSSION. 

I  desire  to  present  five  or  six  photographs  furnished  me  by  Dr.  Carl- 
ton Flint,  of  the  Anatomical  Department  of  Columbia  University, 
showing  the  arrangement  of  the  main  and  accessory  ducts  in  some  of 
the  lower  animals  and  in  the  human  subject. 

Another  point  in  the  anatomy  of  this  region  to  which  I  would  like 
to  call  attention  is  that  the  pancreas  in  the  early  stage  of  its  develop- 
ment is  completely  invested  by  peritoneum  ;  and  that  it  only  becomes 
a  retroperitoneal  organ  by  the  absorption  and  conversion  into  areolar 
tissue  and  fat  of  the  several  layers  of  the  posterior  mesentery. 

This  fact  I  believe  to  be  important  clinically,  for  it  will  be  seen  that 
the  areolar  tissue  and  fat  surrounding  the  pancreas  are  directly  continu- 
ous with  the  perirenal  and  retrocolic  areolar  tissue  on  the  left  side — 
a  fact  which  explains  the  well-known  tendency  in  suppurative  disease 
of  the  pancreas  for  the  pus  to  burrow  toward  the  left  flank,  and  which 
points  out  to  us  surgically  the  necessity  of  making  counter  openings  for 
drainage  in  this  locality. 

It  is  perhaps  unnecessary  to  state  to  this  Association  that  it  is  possible 
to  reach  the  pancreas  by  four  different  routes.  These  routes  are  :  By 
dividing  the  gastrohepatic  omentum  just  above  the  lesser  curvature  of 
the  stomach ;  by  dividing  the  gastrocolic  omentum  just  below  the 
greater  curvature  of  the  stomach ;  by  dividing  the  transverse  meso- 
colon, and  by  reflecting  the  parietal  peritoneum  through  a  lumbar 
incision  until  the  perirenal  fat  is  reached,  which  is  continuous  with  the 
areolar  tissue  surrounding  the  pancreas. 

Without  entering  on  a  discussion  of  the  pathology  of  this  condition, 
which  will  be  taken  up  by  Dr.  Opie,  I  desire  to  offer  one  suggestion,  and 
that  is  the  probable  causative  relationship  between  an  enlarged  and 
relaxed  orifice  of  the  ampulla  of  Vater  due  to  the  frequent  passage  of 
biliary  calculi  and  inflammatory  diseases  of  both  the  bile  duct  and  the 
pancreatic  duct,  for  it  is  a  well-known  and  generally  recognized  fact  that 
in  other  situations  of  the  body  where  a  similar  arrangement  is  found, 
of  ducts  emptying  into  septic  cavities,  that  whenever  the  sphincteric 
action  of  the  orifice  is  destroyed  infection  readily  ascends  to  the 
mucous  membrane  of  the  duct,  giving  rise  to  an  inflammatory  con- 
dition which  may  vary  in  intensity  from  a  mild  catarrhal  condition  to 
a  severe,  rapidly  fatal  interstitial  inflammation  of  the  entire  gland.  I 
also  desire  to  speak  of  the  probably  digestive  action  of  the  pancreatic 
juice  when  allowed  to  percolate  into  the  connective  tissue  surrounding 
the  gland  as  a  cause  of  erosion  of  bloodvessels  and  extensive  necrosis 
in  addition  to  the  well-known  power  which  it  has  of  producing  fat 


ON     PANCREATITIS.  I75 

necrosis.  I  desire,  in  conclusion,  to  refer  to  one  or  two  cases  of  acute 
pancreatitis,  the  autopsies  of  which  furnish  data  which  ought  to  be  placed 
on  record. 

E.  G.,  male,  aged  fifty-three  years,  was  admitted  to  Roosevelt  Hos- 
pital in  August  last.  The  patient  had  complained  of  a  digestive  dis- 
order for  many  years.  Seven  years  ago  he  experienced  an  attack  of 
severe  abdominal  pain  which  was  accompanied  by  fever  and  was  re- 
garded as  an  acute  peritonitis.  From  this  he  fully  recovered.  Five 
days  before  his  admission  he  complained  of  general  abdominal  pain, 
which  gradually  increased  and  was  accompanied  by  vomiting,  fever, 
and  general  malaise.  Free  catharsis  produced  no  relief.  His  symp- 
toms grew  worse.  A  progressive  distention  of  the  abdomen  ensued. 
He  had  sweats,  and  became  extremely  weak  and  prostrated.  On  ad- 
mission his  temperature  was  104.2°  F. ;  pulse,  100,  but  weak  and 
thready;  respiration,  36  and  shallow.  The  abdomen  was  greatly  dis- 
tended ;  tenderness  was  everywhere  present.  No  mass,  no  jaundice, 
no  fluid  wave ;  liver  percussion  normal.  Heart  and  lungs  negative. 
Rectal  examination  negative.     Urine  negative.     Bowels  constipated. 

He  was  seen  by  the  writer  about  midnight,  and,  as  his  condition 
seemed  extremely  critical,  he  was  immediately  prepared  for  operation. 

As  the  clinical  picture  was  one  of  a  general  peritonitis,  the  absence 
of  signs  of  gall-bladder  disease,  or  the  symptoms  of  a  perforative  lesion 
of  other  portions  of  the  alimentary  tract,  led  us  to  a  diagnosis  by  ex- 
clusion of  a  perforated  appendix. 

Under  chloroform  anaesthesia  the  abdomen  was  opened.  There  was 
no  general  peritonitis.  The  appendix  region  was  thoroughly  explored 
and  found  to  be  normal.  The  gall-bladder  region  was  next  examined 
and  nothing  of  an  inflammatory  nature  detected.  As  the  intestines 
were  greatly  distended,  an  obstruction  was  looked  for,  but  not  found. 
All  of  this  was  done  quickly,  as  the  pulse  was  becoming  rapidly  weaker, 
and  the  most  vigorous  stimulation  was  being  employed,  including  a 
hot  saline  infusion. 

The  region  of  the  pancreas  was  next  palpated  through  the  walls  of 
the  stomach  and  omental  tissue,  and  pronounced  negative  by  two  ex- 
aminers. There  was,  however,  noticed  a  large  number  of  small  white 
spots,  generally  distributed  throughout  the  greater  omentum,  the  largest 
being  about  one-sixteenth  of  an  inch  in  diameter.  One  of  these  was 
removed  for  examination,  after  which  the  abdomen  was  qutckly  closed 
with  generous  gauze  drainage. 

The  patient  did  not  rally,  and  died  the  following  day.     A  report 


176  ,  DISCUSSION. 

received  from  the  hospital  pathologist  stated  that  the  small  white 
nodule  was  of  the  nature  of  a  fat  necrosis,  and  the  autopsy  revealed 
the  pancreas  to  be  the  seat  of  a  number  of  small  circumscribed  ab- 
scesses.    The  case  was,  therefore,  one  of  acute  suppurative  pancreatitis. 

Dr.  Eugene  L.  Opie,  of  Baltimore. 

Surgeons  and  pathologists  can  be  grateful  to  Mr.  Robson  for  the 
interest  he  has  aroused  in  the  relation  of  cholelithiasis  to  chronic  pan- 
creatitis. In  his  lecture  published  less  than  a  year  ago  in  the  London 
Lancet  he  proved  conclusively  that  the  induration  so  frequently  ob- 
served at  operation'  for  gallstones  in  the  common  duct  is  due  to 
chronic  interstitial  pancreatitis.  In  two  cases  studied  during  the  past 
year  I  have  found  acute  disease  of  the  pancreas  associated  with  the 
presence  of  a  small  calculus  in  the  common  bile  duct  near  its  termi- 
nation in  the  duodenum,  and  a  review  of  the  literature  has  demon- 
strated the  frequent  coexistence  of  gallstones  and  acute  pancreatitis. 

There  are,  I  believe,  two  mechanisms  which  explain  this  association 
of  gallstones  with  disease  of  the  pancreas.  The  common  bile  duct,  it 
is  well  known,  passes  downward  alongside  of  the  head  of  the  pancreas 
to  terminate  in  the  duodenum.  For  a  short  but  variable  distance  be- 
fore reaching  the  duodenum  it  lies  in  contact  with  the  pancreatic  duct, 
and,  together  with  the  two  ducts,  penetrates  the  wall  of  the  intestine. 
Before  they  open  into  the  duodenum  they  unite  to  form  a  short  com- 
mon channel,  the  diverticulum  of  Vater.  This  diverticulum  is  very 
variable  in  length  and  shape,  but  may  be  roughly  described  as  a  con- 
ical cavity,  at  the  apex  of  which  is  the  common  orifice  of  the  two  ducts, 
while  into  its  base  open  the  orifices  of  the  pancreatic  and  the  bile  duct. 
The  duodenal  orifice  of  the  diverticulum  is  narrower  than  any  part  of 
the  common  bile  duct,  and  here  gallstones  tend  to  lodge.  These  ana- 
tomical features  explain  the  two  mechanisms  by  which  gallstones  may 
produce  lesions  of  the  pancreas. 

A  small  gallstone  may  lodge  in  the  diverticulum  at  the  common 
orifice  of  the  two  ducts.  The  diverticulum,  which  varies  greatly  in 
length,  is  often  seven  to  eight  millimetres  in  length,  while  the  orifice 
has  a  diameter  of  about  two  millimetres,  although  at  times  it  is  much 
narrower.  A  small  stone,  perhaps  from  three  to  five  millimetres  in 
diameter,  might  lodge  in  the  diverticulum  and  occlude  its  duodenal 
orifice,  altKough  it  only  partially  filled  the  cavity  of  the  diverticulum. 
The  orifices  of  the  bile  duct,  the  duct  of  Wirsung  being  unobstructed, 
the  two  ducts  would  be  converted  by  the  occlusion  of  their  common 


ON    PANCREATITIS.  IJJ 

orifice  into  a  continuous  closed  channel,  and  bile  might  be  forced  by 
the  muscular  contractions  of  the  gallbladder  into  the  pancreas.  At  the 
autopsy  performed  upon  a  case  occurring  in  the  service  of  Dr.  Halsted 
at  the  Johns  Hopkins  Hospital  I  found  the  conditions  mentioned.  At 
operation  Dr.  Halsted  noted  foci  of  fat  necrosis  disseminated  through- 
out the  abdomen  ;  the  pancreas  was  greatly  swollen,  blackish-red  and 
hemorrhagic  in  appearance.  The  patient  died  shortly  after  the  oper- 
ation, and  at  the  autopsy,  performed  a  few  hours  after  death,  the  pan- 
creas was  found  to  be  the  seat  of  typical  hemorrhagic  pancreatitis, 
characterized  by  extensive  necrosis  of  tissue  and  accumulation  of  in- 
flammatory exudate.  A  small  gallstone,  three  millimetres  in  diameter, 
was  found  lodged  in  the  diverticulum  of  Vater,  which  was  ten  milli- 
metres in  length  ;  its  orifice  measured  only  one  millimetre  in  diameter. 
The  stone  had  plugged  the  duodenal  orifice  of  the  diverticulum,  but,  only 
partially  filling  its  cavity,  did  not  occlude  either  bile  or  pancreatic 
duct.  Bile  had  penetrated  into  the  pancreatic  duct,  and  its  branches, 
which  mar  the  duodenum,  were  still  intact,  ind  had  stained  them  a 
bright-green  color.  Cultures  from  the  pancreas  remained  sterile. 
Bile  had  made  its  way  into  the  parenchyma,  and  its  presence  was  asso- 
ciated with  acute  hemorrhagic  pancreatitis. 

It  has  been  shown  that  a  variety  of  irritating  substances  injected 
into  the  pancreatic  duct  of  animals  will  produce  acute  hemorrhagic 
pancreatitis  resembling  that  in  the  human  being.  Flexner  and  others 
have  produced  the  lesion  by  the  injection  of  artificial  gastric  juice, 
acids,  alkalies,  dilute  formalin,  and  suspensions  of  a  variety  of  bacteria. 
The  autopsy  referred  to  suggested  the  possibility  that  bile  might  also 
produce  the  lesion,  and  experiments  were,  therefore,  made  on  dogs. 
About  five  cubic  centimetres  of  bile  obtained  from  the  gall-bladder  of 
the  same  dog,  or  from  that  of  a  second  dog,  were  injected  into  the 
pancreatic  duct.  In  four  instances  hemorrhagic  pancreatitis,  accom- 
panied by  focal  fat  necrosis,  resulted,  and  in  two  of  these  cases  the 
lesion  was  fatal  within  twenty-four  hours,  wide-spread  necrosis  of  the 
abdominal  fat  being  present.  Smaller  amounts  of  bile  produced  less 
marked  lesions.  These  facts,  I  believe,  demonstrate  that  one  at  least 
of  the  causes  of  hemorrhagic  pancreatitis  is  the  penetration  of  bile  into 
the  pancreas,  and  explain  the  previously  noted  association  of  chole- 
lithiasis with  hemorrhagic  and  gangrenous  pancreatitis,  the  latter  being 
doubtless  a  late  stage  of  the  hemorrhagic  lesion. 

There  is  a  second  mechanism  by  which  gallstones  can  produce 
changes  in  the  pancreas.     Should  a  gallstone  of  large  size  passing 

Am  Surg  13 


1/8  DISCUSSION. 

along  the  common  duct  become  impacted  in  the  diverticulum,  it 
would  not  only  block  the  common  orifice  of  the  two  ducts,  but  would 
at  the  same  time  occlude  the  common  bile  duct  and  the  duct  of  Wir- 
sung,  so  that  bile  would  be  dammed  back  upon  the  liver  and  the  pan- 
creatic juice  upon  the  pancreas.  In  this  case  bile  could  not  enter  the 
pancreas.  In  order  to  occlude  the  pancreatic  duct  it  would  not  be 
necessary  for  the  gallstone  to  enter  the  diverticulum,  since,  if  it  should 
lodge  in  the  bile  duct  just  above  the  diverticulum,  where  the  two 
ducts  are  separated  only  by  a  thin  septum,  the  pancreatic  duct  might 
be  compressed  and  obstructed.  In  a  limited  number  of  cases  the 
lesser  duct  of  Santorini  anastomoses  with  the  larger  pancreatic  duct, 
and  hence  provides  an  additional  outlet  for  the  secretion  of  the  gland. 
It  is  well  known  that  occlusion  of  the  pancreatic  duct  by  calculi  or  by 
carcinoma  of  the  head  of  the  pancreas  is  followed  by  a  chronic  inter- 
stitial inflammation  of  the  gland.  When  the  pancreatic  ducts  of  an 
animal  are  ligated  inflammation  ensues.  The  chronic  interstitial  pan- 
creatitis, which  Mr.  Robson  has  shown  not  infrequently  accompany 
cholelithiasis,  is  doubtless  due  to  occlusion  of  the  pancreatic  duct  by 
gallstones  impacted  in  the  common  duct  near  its  termination  or  in  the 
diverticulum  of  Vater. 

The  association  of  pancreatic  disease  with  the  presence  of  gallstones 
in  the  common  duct  and  diverticulum  of  Vater  appears  to  be  of  con- 
siderable surgical  importance.  Acute  or  chronic  pancreatitis  is  a  pos- 
sible complication  in  every  case  of  cholelithiasis.  The  induration  of 
chronic  inflammation  observed  at  operation  for  gallstones  has  been 
mistaken  for  malignant  disease.  The  presence  of  abdominal  fat  ne- 
crosis, or  of  hemorrhagic  or  gangrenous  pancreatitis,  should  suggest  the 
possible  presence  of  a  gallstone  in  the  diverticulum  of  Vater,  and 
should  it  remain  so  impacted  the  existing  alteration  of  the  pancreas 
can  only  increase  in  severity. 

Dr.  J.  W.  Elliot,  of  Boston. 

This  contribution  is  one  of  the  most  important  we  have  recently 
had  to  the  surgery  of  the  gall-bladder,  and  since  reading  Dr.  Rob- 
son's  paper  in  July,  my  own  experience  has  confirmed  his  observa- 
tions. I  can  recall  one  case  of  persistent  jaundice  where,  having  ex- 
plored the  gall-bladder  and  found  no  stone,  but  an  abundance  of  black 
bile  and  a  thickened  pancreas,  I  told  the  patient  she  was  probably 
suffering  from  malignant  disease  of  the  pancreas.     She  came  to  me 


ON    PANCREATITIS.  179 

two  years  later,  looking  fat  and  feeling  well.     This  was  undoubtedly  a 
case  of  chronic  pancreatitis  obstructing  the  gall  duct. 

Another  case  of  chronic  pancreatitis  which  was  associated  with  gall- 
stones occurred  in  my  practice  last  March,  and  is  interesting  as  show- 
ing why,  with  stones  in  the  gall-bladder,  we  so  frequently  have  the 
symptom  of  jaundice.  Theoretically,  if  the  common  duct  were  not 
blocked  there  would  be  no  jaundice ;  but  practically,  surgeons  know 
that  with  stones  only  in  the  gall-bladder  there  is  frequently  jaundice. 
The  case  was  one  of  a  man  of  middle  age,  who  had  lost  much  flesh 
and  had  an  increasing  and  persistent  jaundice.  The  gall-bladder  was 
opened  and  the  stones  removed.  None  were  found  in  the  cystic  duct 
nor  in  the  common  duct.  The  pancreas  was  much  enlarged  and  filled 
with  blebs.  I  thought  it  was  either  a  case  of  cancer  of  the  pancreas 
or  a  chronic  pancreatitis.  No  bile  escaped  at  the  time  of  operation, 
but  did  so  soon  after,  and  the  jaundice  slowly  disappeared.  The  gall- 
bladder closed  and  the  stools  became  normal  in  color.  The  man 
came  back  two  months  later,  having  gained  all  the  flesh  he  had  lost, 
and  seemed  to  be  perfectly  well.  In  this  case  I  simply  drained  the  gall- 
bladder, and  as  there  was  no  stone  in  the  common  duct  the  jaundice 
must  have  been  caused  by  the  enlarged  pancreas,  the  drainage  secur- 
ing a  perfect  cure.  In  such  cases  I  suppose  the  gallstones  give  rise  to 
a  mild  cholangitis,  which  extends  into  the  pancreatic  duct,  giving  rise 
in  turn  to  a  chronic  pancreatitis,  which  obstructs  the  common  bile 
duct. 

Dr.  George  W.  Fowler,  of  Brooklyn,  N.  Y. 

I  entirely  agree  in  the  opinion  expressed  that  all  cases  upon  this 
subject  should  be  recorded,  and  I  wish  to  report  three  that  have  come 
under  my  observation.  The  first  one  was  several  years  ago,  and  very 
little  was  known  about  the  disease  at  that  time.  The  patient  gave  a 
history  of  some  grave  abdominal  lesion,  the  main  feature  being  in- 
tense abdominal  pain.  Exploratory  operation  showed  fat  necrosis,  and 
a  large  number  of  orange-colored  droplets  came  into  view.  There  was 
a  large  amount  of  rather  thin  dark  material  in  the  region  of  the  pan- 
creas, and  the  lesion  undoubtedly  had  its  origin  in  the  head  of  that 
organ.  Drainage  was  instituted,  but  the  patient  died  in  a  few  hours, 
the  autopsy  revealing  the  true  lesion. 

The  second  case  was  a  woman  who  was  brought  to  me  with  peculiar 
symptoms  of  intense  prostration.     Her  condition  would  not  permit  of 


l80  DISCUSSION. 

operation  at  the  time,  but  the  next  morning  she  had  rallied  somewhat, 
and  preparations  were  made  to  operate.  While  these  were  going  on 
she  again  passed  into  a  state  of  extreme  collapse,  and  the  operation 
had  to  be  abandoned.  She  finally  rallied  sufficiently  to  permit  us  to 
open  the  abdomen.  Hemorrhagic  pancreatitis  was  found,  and  drainage 
instituted,  the  patient  m^aking  a  good  recovery. 

The  third  case  was  a  man  who  came  with  a  history  of  obscure  diges- 
tive disturbances  and  attacks  of  jaundice  for  several  years.  He  was 
supposed  to  be  suffering  from  ordinary  biliary  colic ;  the  collapse  present 
was  similar  to  the  last  case.  After  waiting  some  time  for  him  to  re- 
cover from  the  collapse,  the  operation  was  finally  instituted,  and  the 
conditions  found  as  already  described.  I  do  not  know  that  this  symp- 
tom of  repeated  attacks  of  extreme  collapse  has  been  dwelt  upon  at 
any  length.  It  is  mentioned  in  the  literature,  but  is  not  sufficiently  em- 
phasized in  the  symptomatology  of  the  disease.  I  wish  to  call  atten- 
tion to  it,  and  to  ask  Dr.  Robson  if  he  has  noticed  it  to  be  a  promi- 
nent feature. 

Dr.  N.  B.  Carson,  of  St.  Louis. 

The  last  speaker  says  that  all  cases  should  be  reported,  and  I  agree 
with  him.  I  have  had  one  case  in  a  young,  fleshy  lady,  who  gave  a 
history  of  numerous  attacks  of  indigestion.  I  diagnosed  chronic  ap- 
pendicitis, and  on  operating  I  found  the  appendix  enlarged  and  thick- 
ened. I  supposed  that  she  had  made  a  good  recovery ;  but  when  I  saw 
her  subsequently  she  stated  that  she  had  been  suffering  for  a  whole 
year.  She  complained  of  having  had  numerous  attacks  resembling 
gallstones,  and  was  highly  jaundiced.  She  had  been  jaundiced  before, 
but  would  recover,  and  then  have  another  attack.  These  continued 
for  some  time,  and  I  diagnosed  a  probable  pancreatitis  and  possibly 
gallstones.  I  advised  operation  in  order  to  explore  and  settle  the 
question.  Upon  operation  I  found  the  gall-bladder  very  much  thick- 
ened and  slightly  enlarged.  On  opening  the  gall-bladder  a  large 
amount  of  clear  mucus  came  out,  followed  by  black  gall.  On  ex- 
ploring the  abdomen  I  found  the  pancreas  much  indurated.  I  attached 
the  gall-bladder  to  the  abdominal  wall,  and  the  patient  made  a  slow 
recovery.  Just  before  leaving  home  I  had  a  report  from  her  attend- 
ing physician,  stating  that  she  had  had  subsequent  attacks  resembling 
indigestion,  but  that  they  were  not  accompanied  with  jaundice  similar 
to  the  previous  attacks  before  the  operation.  The  interesting  fact  was 
how  to  explain  the  discharge  of  clear  mucus  which  preceded  the  bile. 


ON    PANCREATITIS.  l8l 

When  the  bile   assumed  a  natural  color  the  patient  commenced  to 
improve. 

Dr.  W.  L.  Estes,  of  South  Bethlehem,  Pa. 

I  wish  to  add  another  case  to  the  list  of  chronic  interstitial  pan- 
creatitis simulating  carcinoma.  My  patient  was  a  very  robust  man, 
who  had  for  six  months  pronounced  jaundice,  with  symptoms  which 
indicated  empyema  of  the  gall-bladder.  At  the  operation  I  found  a 
stone  at  the  neck  of  the  cystic  duct,  extending  down  far  enough  to 
impede  the  flow  of  bile  into  the  common  duct.  The  head  of  the 
pancreas  was  a  nodular  mass,  which  I  diagnosed  as  carcinoma,  and 
gave  a  bad  prognosis.  The  man  recovered  from  the  operation,  and 
made  a  very  rapid  recovery  from  the  condition  of  fat  necrosis.  The 
extreme  weakness  disappeared,  and  he  is  to-day  a  very  robust  police- 
man. 

I  remember  another  case  following  injury,  which  is  interesting  in 
light  of  Dr.  Brewer's  exposition  of  the  anatomy  and  embryology  of 
the  pancreatic  region.  The  man  had  attempted  to  stop  a  runaway 
horse,  and  was  struck  in  the  abdomen  a  little  above  the  umbilical  re- 
gion. He  did  not  pay  much  attention  to  it  at  the  time,  but  the  next 
day  had  pain  in  the  abdomen  and  some  swelling.  This  distention 
increased,  and  he  was  treated  at  his  home  for  five  weeks,  during  which 
time  he  became  progressively  anaemic,  and  lost  flesh  to  an  amazing 
degree,  going  down  from  156  pounds  to  95.  He  had  a  very  large 
tumor,  occupying  the  whole  upper  quadrant  of  the  abdomen,  follow- 
ing the  curvature  of  the  diaphragm  ;  a  very  tense,  elastic  tumor,  which 
reached  from  the  diaphragm  to  a  little  below  the  umbilicus.  The 
whole  upper  part  of  the  abdomen  was  the  seat  of  the  tumor,  and  this 
was  what  puzzled  me.  The  enlargement  was  slightly  greater  on  the 
left  side,  and  I  thought  perhaps  there  was  a  retroperitoneal  hemor- 
rhage. I  expected  to  find  a  large  blood-clot  and  some  serum,  and 
upon  operation  I  found  about  two  thousand  cubic  centimetres  of  bloody 
serum.  Although  the  stomach  was  stretched  over  this  mass  so  tensely 
that  it  seemed  incapable  of  receiving  anything  within  it,  the  man  had 
been  able  to  take  food  in  small  quantities,  but  usually  rejected  it.  The 
stomach  could  not  have  held  more  than  five  cubic  centimetres  at  any 
time.  I  incised  the  cyst,  drained  it,  washed  it  out,  and  sutured  the 
opening  to  the  skin  in  the  left  lumbar  region.  I  had  the  fluid  ex- 
amined, and  found  it  to  be  pancreatic.  Another  and  an  interesting 
physiological  feature  was  that  we  collected  from  the  cyst  from  fifteen 


l82  DISCUSSION. 

hundred  to  twenty-two  hundred  cubic  centimetres  of  serum  in  a  day 
of  twenty  hours.     The  man  made  a  slow  but  complete  recovery. 

His  skin  about  the  opening  of  the  sinus,  which  led  into  the  cyst,  suf- 
fered extensive  excoriation  from  the  discharging  fluid,  and  as  all  fatty 
protection  was  quickly  digested,  it  was  very  difficult  to  prevent  the 
formation  of  a  large  superficial  ulcer.  Frequent  bathings  with  boric 
acid  solution  and  frequent  changes  of  dressing  availed  to  prevent  any 
deep  implication  of  the  skin,  and  finally  a  closely  fitting  tube  inserted 
deep  down  into  the  cyst,  with  its  external  end  inserted  into  a  flask, 
which  was  fastened  to  his  side,  served  to  conduct  away  the  fluid  and 
to  collect  it.  Many  examinations  and  measurements  of  this  fluid 
were  made,  and  there  can  be  no  doubt  of  its  nature  and  its  source. 

Dr.  Leonard  Freeman,  of  Denver. 

I  wish  to  refer  to  a  case  in  which  marked  jaundice  had  existed  for 
some  time,  with  all  the  symptoms  of  a  stone  in  the  common  duct, 
although  at  the  operation  no  stone  was  found.  A  very  much  thick- 
ened, small  and  chronically  inflamed  gall-bladder,  however,  seemed 
to  give  evidence  that  it  had  contained  a  calculus,  which  I  imagined 
had  been  recently  expelled,  perhaps  during  the  operation.  Although 
the  pancreas  was  extremely  hard  and  its  head  unusually  large,  it  did 
not  occur  to  me  to  suppose  the  symptoms  had  been  due  to  the  pan- 
creatic disease.  May  not  symptoms  accredited  to  the  pancreas  some- 
times be  due  to  stones  which  afterward  escape,  before  or  during  the 
operation  ? 

Dr.  Robson.  As  to  the  remarks  made  by  one  of  the  speakers,  that 
gallstones  may  be  present  without  being  discovered,  I  would  state  that 
in  some  of  the  cases  related  I  was  unable  to  feel  any  stones,  while  in 
others  I  could  say  positively  they  were  not  there ;  but  I  do  believe 
that  in  nearly  all  the  cases  gallstones  had  been  present  at  some  time. 
The  cases  related  by  the  several  speakers  are  very  interesting,  and 
they  show  that  this  disease  is  very  much  more  common  than  we  have 
thought.  I  have  spoken  with  a  large  number  of  gentlemen  who  are 
frequently  operating  in  this  region,  and  they  have  nearly  all  told  me 
of  cases  they  had  seen. 

I  was  very  much  interested  in  what  Dr.  Fowler  said  about  the  col- 
lapse which  occurred  in  his  cases,  and  I  believe  it  does  very  frequently 
occur.     I  have  seen  it  in  two  cases,  but  not  to  the  same  extent  as  that 


ON    PANCREATITIS.  183 

mentioned.  I  should  very  much  like  to  know  what  treatment  was 
employed  for  the  collapse,  and  what  was  the  result. 

(Dr.  Fowler  reported  that  strychnine  was  employed.) 

I  remember  that  in  one  case,  where  the  collapse  forbade  operation 
and  persisted,  the  patient  died  without  my  having  been  able  to  get 
him  into  condition  for  operation. 

Dr.  Opie  raised  several  very  interesting  questions,  and  I  had  an  op- 
portunity this  morning  of  seeing  several  of  his  beautiful  specimens. 
I  was  very  much  interested  in  them.  One  cannot  help  but  feel  that 
the  entrance  of  bile  into  the  pancreatic  ducts  may  offer  an  explana- 
tion for  some  of  these  cases  of  hemorrhagic  pancreatitis.  I  think  it 
may  be  rather  the  result  of  infection  than  of  simple  injection  of  bile 
into  the  pancreatic  ducts.  It  will  certainly  be  interesting  to  hear 
further  of  the  results  of  Dr.  Opie's  investigations. 

I  enjoyed  very  much  Dr.  Brewer's  description  of  the  anatomy  of  the 
pancreas,  and  it  may  be  that  the  little  accessory  duct  is  a  very  impor- 
tant factor.  In  one  specimen  of  Dr.  Opie's  that  I  saw  this  morning 
there  is  a  small  stone  in  the  diverticulum,  and  in  one  of  my  cases  I 
removed  a  stone  from  the  lower  part  of  the  common  duct.  This  was 
a  case  of  chronic  pancreatitis  and  not  hemorrhagic.  Where  the  gall- 
stone is  large  we  may  actually  get  the  bile  forced  into  the  little  acces- 
sory duct. 


THE  SURGICAL  TREATMENT   OF  CHRONIC  ULCER 
OF  THE  STOMACH. 


By  a.  W.  mayo  ROBSON,  F.R.C.S., 

LEEDS,    ENGLAND, 

SENIOR   SURGEON   TO   THE   GENERAL   INFIRMARY  AT  LEEDS  ;   EMERITUS   PROFESSOR 

OF  SURGERY  IN  THE  YORKSHIRE  COLLEGE  OF  THE  VICTORIA  UNIVERSITY. 


Mr.  President:  I  must  first  thank  you,  sir,  most  sincerely 
for  the  kind  invitation  which  you  personally  and  the  Council 
of  the  American  Surgical  Association  have  extended  to  me  in 
asking  me  to  take  part  in  your  proceedings,  an  honor  which  I 
very  highly  appreciate.  The  subject  of  the  "  Surgical  Treat- 
ment of  Ulcer  of  the  Stomach"  is  one  that  has  for  some  time 
and  is  now  attracting  the  attention  of  surgeons  all  over  the 
world,  so  that  I  hope  I  shall  need  to  make  no  apology  for  ven- 
tilating my  views  before  this  important  Surgical  Association. 

The  treatment  of  gastric  ulcer  is  at  first  essentially  medical, 
and  when  properly  carried  out  and  for  a  sufficient  length  of 
time  it  is  usually  completely  successful.  Leube  says  that  one- 
half  or  three- fourths  of  all  cases  will  be  cured  by  four  or  five 
weeks  of  treatment,  but  if  not  cured  in  that  time  they  will  not 
be  cured  by  medical  treatment  alone,  a  view  in  which  I  thor- 
oughly concur.  Unfortunately,  however,  in  many  cases,  treat- 
ment is  stopped  as  soon  as  relief  to  pain  is  obtained  and  long 
before  the  ulcer  is  healed.  In  some  cases  this  may  be  due  to 
the  uncertainty  of  the  diagnosis  or  from  the  impatience  of  the 
patient;  perhaps,  in  others,  to  ignorance  as  to  how  long  it  takes 
to  secure  the  healing  of  a  gastric  ulcer.  The  earlier  in  the  course 
of  the  disease  that  radical  treatment,  in  the  shape  of  dieting  and 
rest,  is  adopted  the  less  prolonged  will  the  treatment  need  to  be 
and  the  more  likely  is  it  to  be  effectual ;  but  probably  the  very 


CHRONIC    ULCER    OF    THE    STOMACH.  185 

earliest  time  that  a  patient  should  be  allowed  to  be  out  of  bed  is 
from  a  fortnight  to  a  month  after  all  pain  and  tenderness  have 
disappeared. 

Failing  this  thorough  treatment  relapses  will  be  certain  to 
occur,  and  in  the  long  run  complications  will  supervene  or  the 
ulcer  will  become  chronic,  when,  though  medical  treatment  may- 
relieve  in  some  cases,  cure  can  only  be  looked  for  in  the  greater 
number  by  surgical  methods. 

In  considering  the  treatment  of  ulcer  of  the  stomach,  it  is 
useful  to  hold  in  view  the  course  of  an  ulcer  of  the  leg,  which 
directly  the  healing  stage  has  arrived  becomes  free  from  pain  ; 
but  this  neither  indicates  that  healing  is  completed  nor  that 
care  may  cease,  and  should  treatment  be  abandoned  and  the 
ulcer  become  chronic,  though  it  may  even  then  be  painless,  it 
is  at  any  time  liable  to  become  inflamed. or  to  extend;  more- 
over, the  surrounding  tissues  become  infiltrated  with  lymph 
which  tends  to  organize,  and  this  in  a  hollow  viscus  soon  ends 
in  stricture,  as  in  the  leg  it  tends  to  drag  on  the  surrounding 
skin  and  produce  constriction  of  the  limb. 

The  surgical  treatme?tt  of  intractable  or  relapsing  gastric  ulcer 
is  in  the  greater  number  of  cases  the  only  satisfactory  method 
of  dealing  with  these  refractory  cases,  and  operation  should 
be  resorted  to  at  a  much  earlier  period  than  has  hitherto  been 
the  custom,  and  always  before  the  patient  is  so  far  reduced  by 
pain  and  starvation,  or  the  supervention  of  serious  complica- 
tions, that  weakness  and  anaemia  render  any  operative  proce- 
dure hazardous. 

Ulcer  of  the  stomach  is  a  much  more  serious  matter  than  is 
generally  recognized,  for,  according  to  various  authors,  it  has  a 
mortality  when  treated  by  general  and  medical  means  only  of 
from  20  to  50  per  cent. 

Dr.  Einhorn,  in  his  well-known  work  on  Diseases  of  the  Stom- 
ach (p.  223),  says  :  "At  first  glance  it  would  appear  that  the 
prognosis  of  gastric  ulcer  is  quite  good,  especially  nowadays, 
when  the  diagnosis  of  the  affection  is  usually  made  at  an  early 
date.  However,  if  we  take  into  consideration  the  tabulated 
statistics  given  by  Debove  and  Remond  (page  276),  in  reference 


I  86  ROB  SON, 

to  the  outcome  of  all  cases  of  ulcer,  we  become  more  careful  in 
our  favorable  predictions." 

This  table  gives  in  a  hundred  cases  of  ulcer : 

Perfect  cure .     50 

Perforation  and  peritonitis  .         .         .         .         .         .         .         •     13 

Foudroyant   hasmatemesis     .........       5 

Pulmonary   tuberculosis         .         .         .         .         .         .         .         .         .20 

Inanition         ............       5 

Different  complications  .........       7 

The  excuses  of  a  few  years  ago,  that  there  is  a  great  respon- 
sibility in  recommending  surgical  treatment,  either  from  the  un- 
certainties of  diagnosis  or  from  the  risk  of  operation,  can  no 
longer  avail,  since  the  diagnosis  of  gastric  ulcer,  thanks  to  the 
researches  of  Ewald,  Hemmeter,  Hinborn  and  others,  has  been 
brought  to  a  greater  state  of  perfection  than  exists  in  many 
other  obscure  diseases,  where  radical  treatment  has  to  be 
adopted  on  much  more  slender  foundations ;  and  fortunately, 
now  that  the  mortality  in  operations  for  simple  diseases  of  the 
stomach,  excluding  perforation  and  hemorrhage,  has  been  re- 
duced in  the  hands  of  experienced  surgeons  to  about  5  per  cent., 
the  great  risks  of  surgical  treatment  cannot  be  advanced  even 
by  its  most  ardent  opponents. 

We  have  to  consider  not  only  the  treatment  of  gastric  ulcer 
itself,  but  also  that  of  all  its  complications,  which  are  no  less 
numerous  than  serious.     They  are  as  follows : 

1.  Local  peritonitis  or  perigastritis  ending  in  adhesions. 

2.  Local  peritonitis   ending  in  suppuration  and  a  localized 
abscess. 

3.  Subphrenic  abscess. 

4.  Abscess  of  liver,  pancreas,  or  spleen. 

5.  Fistula  between  the  stomach  or  pylorus   and  adjoining 
organs,  or  with  the  surface  of  the  body. 

6.  Acute  perforation  of  the  stomach  wall. 

7.  General  peritonitis. 

8.  Haematemesis  and  mela^na. 

9.  Dilatation  of  the  stomach. 

10.  Tumor  of  stomach  or  pylorus. 


CHRONIC    ULCER    OF    THE    STOMACH.  187 

11.  Cicatricial  stenosis  of  pylorus. 

12.  Hour-glass  stomach. 

13.  Spasm    of    pylorus,   producing    intermittent    narrowing 
(Reichman's  disease). 

14.  Atonic  motor  deficiency. 

15.  Severe  gastralgia. 

16.  Persistent  vomiting. 

17.  Tetany. 

18.  Acute  or  chronic  pancreatitis. 

19.  Profound  anji^mia,  resembling  the  pernicious  form. 

20.  Pressure  on  or  stricture  of  the  bile  ducts,  with  jaundice. 

21.  Catarrh  of  gall-bladder  from  adhesions  producing  attacks 
like  those  of  cholelithiasis. 

22.  Great  loss  of  flesh  and  strength  ending  in  phthisis. 

23.  Cancer  secondary  to  ulcer.     "  Ulcus  carcinomatosum." 
We  are  not  prepared  to  subscribe  fully  to  the  views  of  Tri- 

comi/  who  draws  a  parallel  between  the  treatment  of  hernia 
and  that  of  ordinary  gastric  ulcer,  and  proposes  that,  as  hernia 
is  treated  radically  with  success,  so  gastric  ulcer  should  be 
treated  radically  by  the  performance  of  gastro -enterostomy. 
Heydenreich-  argues  :  "  The  death  rate  from  all  cases  of  gastric 
ulcer  is  from  25  to  30  per  cent.,  but  from  gastro-enterostomy 
only  16.2  per  cent.  ;  therefore,  the  operation  has  less  danger 
than  the  disease." 

The  question  of  medical  vs.  surgical  treatment  in  this  class  of 
cases  is,  however,  one  that  can  be  much  simplified  by  a  careful 
study  of  statistics. 

At  the  time  I  delivered  the  Hunterian  Lectures,  in  March, 
1900,  I  had  been  able  to  collect  from  various  sources  188  opera- 
tions on  the  stomach  for  gastric  ulcer  (excluding  those  for  per- 
foration and  hemorrhage),  of  which  157  recovered  and  31  died, 
thus  giving  a  mortality  of  16.4  per.  cent.  These  included  34 
personal  cases. 

Now,  although  the  deaths  from  gastric  ulcer  medically 
treated  averaged  25  per  cent.,  taking  a  low  estimate,  and  those 

1  Riforma  Medica,  1889.  -  Sem.  Med.,  February  2,  1898. 


l88  ROBSON, 

from  even  the  worst  and  most  inveterate  cases  of  ulcer,  when 
treated  surgically,  only  i6  per  cent,  at  the  time  of  those  lectures, 
yet  the  difference  did  not  then  appear  so  great  as  to  make  it 
desirable  or  prudent  very  strongly  to  advocate  surgical  treat- 
ment until  the  disease  became  chronic  or  until  serious  compli- 
cations had  ensued. 

To-day,  however,  the  facts  are  very  materially  altered  by  the 
all-round  improvement  in  operations  on  the  stomach,  and  the 
contrast  of  25  per  cent,  of  deaths  in  cases  treated  medically,  and 
5  per  cent,  as  shown  in  our  latest  statistics  in  those  treated 
surgically,  in  the  worst  and  most  complicated  cases,  is  so  strik- 
ing that  we  feel  it  incumbent  to  urge  most  strongly  that, 
although  cases  of  gastric  ulcer  should  first  be  submitted  to 
medical  treatment,  yet  if  such  treatment  fails  to  cure  in  a  rea- 
sonable time,  or  if  relapses  occur  on  the  resumption  of  solid 
food,  then  surgical  should  give  place  to  medical  treatment ;  for 
it  is  unfair  to  the  surgeon  to  hand  over  to  him  almost  moribund 
cases,  and  it  is  unjust  to  the  patients  to  persist  in  dosing  them 
with  medicine,  or  otherwise  treating  palliatively,  cases  that  can 
only  be  benefited  or  cured  by  surgical  means. 

Operative  Treatment.  Before  the  abdomen  is  opened  it  is 
quite  impossible  to  say  what  operation  or  operations  will  be  re- 
quired, and  the  surgeon  must  be  prepared  to  adapt  himself  to 
circumstances  on  discovering  the  position  of  the  ulcer  and  the 
conditions  associated  with  it,  especially  as  to  the  presence  or 
absence  of  adhesions  and  other  complications. 

Any  one  of  the  following  operations  or  a  combination  of  one 
or  more  may  be  called  for  in  each  individual  case:  Exploratory 
gastrotomy ;  gastro-enterostomy  to  secure  physiological  rest  to 
the  stomach  and  relieve  the  hyperchlorhydria,  or  in  other  cases 
to  short-circuit  a  stenosis;  excision  of  the  \x\ccr  \  pylorectomy  ; 
pyoroplasty  ;  gastroplasty  ;  gastrogastrostomy  ;  gastrolysis  ;  pylo- 
rodiosis  ;  gastroplication. 

The  Preparation  of  the  Patient.  It  has  been  the  custom  with 
many  surgeons  to  put  stomach  patients  through  a  long  course 
of  preliminary  treatment,  such  as  frequent  lavage  of  the  stom- 
ach and  abstention  from   food  before   operation  ;  this,  as  a  rule. 


CHRONIC    ULCER    OF    THE     STOMACH.  189 

is  quite  unnecessary,  and  certainly  inadvisable  in  the  greater 
number  of  cases  ;  first,  because  the  treatment  is  depressing  and 
debilitating  in  the  case  of  patients  already  exhausted  by  long 
illness  ;  secondly,  as  proved  by  Dr.  Harvey  Cushing's  bacterio- 
logical investigations,  the  stomach  contents  speedily  become 
aseptic  if  the  mouth  be  cleansed  and  aseptic  foods  admin- 
istered ;  and  thirdly,  as  proved  by  ample  clinical  experience, 
elaborate  preliminary  treatment  is  unnecessary  to  success. 

If  the  stomach  is  greatly  dilated  and  the  contents  are  foul, 
then  lavage  with  simple  boiled  water  night  and  morning  is 
adopted  for  two  days  before  operation.  The  careful  cleansing 
of  the  mouth  and  teeth  and  the  administration  of  foods  steril- 
ized by  boiling  is  advisable.  The  last  meal  is  given  the  night 
before,  about  twelve  hours,  the  stomach  is  washed  out  about 
two  hours,  and  a  nutrient  enema  given  about  an  hour  before 
operation. 

In  other  cases  no  lavage  is  adopted,  but  the  same  care  is  ex- 
ercised in  cleansing  the  mouth,  giving  sterilized  food  and  admin- 
istering a  nutrient  enema,  consisting  of  one  ounce  of  brandy, 
one  ounce  of  liquid  peptonoids,  and  ten  ounces  of  normal  saline 
solution.  Every  patient  is  enveloped  in  a  suit  of  cotton-wool, 
made  by  the  nurse  out  of  gamgee  tissue,  and  each  has  an  in- 
jection of  ten  minims  of  liq.  strychninae,  B.  P.,  administered 
subcutaneously  before  the  operation  is  begun. 

The  preparation  of  the  skin  and  other  aseptic  details  of  the 
operation  differ  in  no  respect  from  those  observed  in  operations 
generally. 

Exploratory  gastrotomy ^  or  opening  the  stomach  by  a  free  in- 
cision in  its  anterior  wall,  is  an  operation  occasionally  called  for 
in  the  surgical  treatment  of  ulcer. 

[a)  In  order  to  verify  the  diagnosis  of  ulcer  when  there  is  so 
much  thickening  of  the  stomach  walls  as  to  suggest  the  pres- 
ence of  cancer. 

{b)  When,  although  the  symptoms  have  pointed  to  ulcer  as 
the  cause  of  the  gastric  trouble,  the  stomach,  on  exposure,  be- 
trays no  evidence  of  puckering  or  other  characteristic  signs, 
and  when,  in  order  to  verify  the  diagnosis  and  ascertain  what  is 


190  ROBSON, 

best  to  be  done,  it  is  felt  desirable  to  examine  the   interior  of 
the  organ. 

(c)  In  certain  cases  of  gastrorrhagia  it  is  desirable  to  perform 
exploratory  gastrotomy  in  order  to  find  and  ligature  the  bleed- 
ing vessels  or  to  otherwise  arrest  the  hemorrhage, 

(d)  It  necessarily  forms  part  of  any  operation  for  the  excision 
of  ulcer  of  the  stomach. 

It  is  not  necessary  for  me  here  to  enter  into  any  detailed  de- 
scription of  the  operation,  which  must  be  familiar  to  all  my 
hearers,  and  which  requires  to  be  varied  according  to  the  object 
in  view. 

The  following  are  examples  of  exploratory  gastrotomy  for 
ulcer: 

Man,  aged  thirty-six  years;  symptoms  of  chronic  ulcer  ex- 
tending over  several  years.  On  exposure  of  the  stomach  no  evi- 
dence on  surface  to  indicate  accuracy  of  diagnosis.  Exploratory 
gastrotomy :  discovery  of  large  ulcer  one  and  a  half  by  three 
inches  on  the  posterior  wall  of  the  stomach.  Posterior  gastro- 
enterostomy ;   recovery. 

Acute  gastrorrhagia;  no  evidence  on  exposing  stomach  ;  ex- 
ploratory gastrotomy ;  numerous  bleeding  ulcers  seen,  two  of 
which  were  bleeding  freely,  and  were  ligatured  en  masse  ;  gastro- 
enterostomy ;  recovery. 

Excision  of  ulcer  is,  as  a  rule,  unnecessary,  but  not  always  to 
be  avoided,  as  in  some  cases  of  bleeding  ulcer,  and  in  others 
where  the  thickening  and  induration  render  it  difficult  to  decide 
on  the  absence  of  malignant  disease.  This  was  the  case  in  a 
man,  aged  fifty-four  years,  on  whom  I  operated  in  1891,  when, 
finding  the  pylorus  the  seat  of  diffuse  induration,  excision  of  the 
whole  indurated  area  was  performed  successfully.  A  careful 
examination  of  the  removed  mass  showed  that  the  growth  was 
inflammatory  around  a  chronic  ulcer. 

In  another  middle-aged  man,  where  the  diffuse  induration  was 
suggestive  of  cancer,  the  pylorus  was  opened  and  a  deep  ulcer 
on  the  posterior  wall  successfully  excised,  the  edges  of  the  orig- 
inal incision  as  well  as  the  margins  of  the  posterior  wound  being 
brought  together  in  a  direction  transverse  to  the  axis  of  the 


CHRONIC    ULCER    OF    THE    STOMACH.  I9I 

pylorus  over  a  bone  bobbin,  as  in  the  modified  operation  of 
gastro-enterostomy. 

Rydygier  prefers  excision  of  the  ulcer  to  gastro-enterostomy, 
because  he  believes  that  carcinoma  not  infrequently  develops  in 
the  scar  of  an  old  ulcer. 

After  excision  of  an  ulcer  the  bleeding  from  large  vessels 
must  be  controlled  by  ligature,  but  the  oozing  from  the  smaller 
vessels  will  be  stopped  readily  by  the  continuous  suture  em- 
ployed to  bring  together  the  edges  of  the  wound.  If  the  ex- 
cision involves  the  serous  coat,  a  Lembert  continuous  stitch, 
with  a  silk  or  celluloid  suture,  will  be  necessary.  Should  the 
excision  have  been  near  the  pylorus  the  line  of  suture  must  be 
placed  transversely  to  the  axis  of  the  canal,  so  as  to  avoid 
stricture. 

The  following  cases  are  examples  of  gastric  ulcers  treated  by 
excision : 

Case  I.  Ulcer  of  pylorus  ;  stenosis;  dilatation  of  stomach  ;  excision 
of  ulcer  and  pyloroplasty. — John  W.  R.,  aged  thirty-six  years,  ad- 
mitted to  the  Leeds  Infirmary  with  the  history  of  stomach  trouble  for 
thirteen  years.  Pain  after  food  and  vomiting  were  the  initial  symp- 
toms. Severe  heematemesis  occurred  six  years  after  the  commence- 
ment of  symptoms.  Great  loss  of  flesh  and  weakness  were  followed 
by  inability  to  work,  although  he  had  stomach  lavage  and  other  appro- 
priate treatmentc  On  admission  the  patient  was  very  thin  and  pro- 
foundly weak.  He  weighed  eight  stone.  A  swelling  could  be  felt 
below  the  right  costal  margin.  The  stomach  reached  three  inches 
below  the  umbilicus,  and  there  was  visible  peristalsis.  Free  HCl  pre- 
sent. 

Operation  on  November  15,  1900.  The  pylorus  was  found  very 
much  thickened,  forming  a  nodular  swelling  adherent  to  the  gall- 
bladder and  liver  and  to  the  abdominal  wall  by  omental  adhesions. 
After  separating  the  adhesions  a  small  opening  was  discovered  in  front 
of  the  pylorus,  evidently  the  site  of  a  perforation  which  his  medical 
man,  who  was  present,  said  he  remembered  occurring  some  months 
previously,  and  which  was  then  treated  successfully  by  rest  and  rectal 
feeding. 

The  pylorus  was  freely  laid  open  and  found  to  be  the  site  of  a  round 
perforating  ulcer  in  front  and  another  on  the  posterior  wall.    The  latter 


192  ROBSON, 

had  perforated  into  the  substance  of  the  pancreas.  Both  were  excised, 
thus  practically  constituting  a  pylorectomy.  The  edges  of  the  poste- 
rior wound  were  brought  together  transversely  to  the  axis  of  the  stomach. 
The  anterior  wound  was  prolonged  into  the  duodenum  and  stomach, 
and  its  edges  were  brought  together  transversely  to  the  axis  of  the 
stomach  over  a  bone  bobbin,  thus  leaving  a  capacious  channel  between 
the  stomach  and  duodenum  surrounded  by  healthy  mucous  membrane. 

Recovery  was  uninterrupted,  and  he  was  discharged  on  December 
1 2th,  weighing  8  stone  5  pounds. 

On  January  9,  1901,  he  returned  to  report  himself  well,  and  then 
weighed  9  stone  11  pounds. 

Case  II.  Pyloric  ulcer  treated  by  excision  of  ulcer  and  pyloroplasty. — 
Mrs.  M.  K.,  aged  forty-four  years.  Well  till  two  years  ago,  when  she 
had  colic  and  lost  flesh.  Under  treatment,  recovered  and  gained 
some  of  lost  weight. 

September  15,  1897.  Recurrence  of  attack  similar  to  that  of  a  year 
before,  but  with  pain  at  the  right  side,  over  the  pylorus.  Loss  of  weight 
and  strength.  The  patient  had  for  some  time  been  an  invalid,  and 
had  been  continuously  under  medical  treatment  for  months.  Her 
weight  was  6  stone  11  pounds.  There  was  visible  peristalsis  toward 
the  pylorus,  which  was  fixed  to  the  gall-bladder ;  no  pain  or  tender- 
ness. Liver  two  inches  below  costal  margin,  but  no  nodules,  and  no 
jaundice  present. 

Operation  on  July  23,  1898.  An  ulcer  at  the  pylorus  was  found 
adherent  to  the  liver,  which  formed  its  floor,  and  there  was  stenosis  of 
pylorus.  Pyloroplasty  performed  after  excision  of  the  ulcer,  the  open- 
ing being  sutured  transversely  over  a  bone  bobbin. 

December  T^,  1898.  Had  gained  i  stone  8  pounds  in  weight.  No 
trouble  in  digesting  anything. 

December  23,  1899.  Reported  as  "very  well"  and  of  normal 
weight. 

The  operatioji  of  pylorectomy  for  ulceration  of  the  pylorus  may 
be  conveniently  mentioned  under  the  heading  of  excision  of 
ulcer. 

Dr.  Rodman^  has  collected  from  literature  and  personal  cor- 
respondence detailed  reports  of  forty  pylorectomies,  partial 
gastrectomies,  and  excisions  for  ulcer,  with  six  deaths.     This 

1  Philadelphia  Medical  Journal,  June  9,  1900. 


CHRONIC    ULCER    OF    THE    STOMACH,  I93 

includes  cases  since  1881,  but  the  later  operations,  under  im- 
proved technique,  contrast  favorably  with  the  earlier  ones. 

I  have  myself  performed  the  operation  of  excision  of  gastric 
ulcer  six  times,  all  the  patients  recovering. 

Nevertheless,  the  mortality  after  excision  will  probably  always 
be  higher  than  the  more  simple  operation  of  gastro-enterostomy. 
The  more  severe  and  radical  operation  should,  therefore,  be  re- 
served for  cases  that  are  not  suitable  for  the  less  severe  opera- 
tion, or  in  which  the  suspicion  of  cancerous  degeneration  is 
entertained,  and  cannot  be  disproved  on  naked-eye  inspection. 
The  following  case  is  an  example  : 

Tumor  of pyloi'us  and  chronic  hcematemesis  due  to  ulcer  ;  pylorectoviy. — 
Ini  89 1 1  was  asked  by  a  medical  friend  to  see  a  man,  aged  fifty-four  years, 
who  for  six  months  had  suffered  from  pain  coming  on  an  hour  after 
food,  and  more  recently  from  vomiting  blood,. of  coffee-ground  charac- 
ter, in  considerable  quantities,  so  that  he  was  not  only  reduced  in  flesh 
and  strength,  but  had  also  been  rendered  profoundly  anaemic  by  the 
loss  of  blood. 

A  tumor  of  the  pylorus  could  be  easily  felt,  and  the  stomach  was 
markedly  dilated. 

As  he  was  rapidly  losing  ground,  an  operation  was  performed,  and 
the  pylorus  was  found  thickened  and  nodular,  with  adhesions  to  the 
liver  and  omentum. 

After  separating  the  adhesions  the  pylorus  was  excised,  and  the  open 
end  of  the  duodenum  was  fixed  to  the  opening  in  the  stomach  by 
means  of  two  lines  of  sutures  without  the  use  of  a  bobbin,  the  rest  of 
the  stomach  aperture  being  closed  by  a  double  layer  of  sutures.  The 
tumor  proved  to  be  inflammatory  around  an  open  ulcer,  which  had 
been  the  source  of  the  hemorrhage.  The  bleeding  was  not  repeated, 
and  the  patient  rapidly  gained  flesh,  and  returned  home  within  the 
month. 

The  subsequent  history  of  this  case  is  interesting  on  account 
of  cicatricial  contraction  of  the  new  pyloric  aperture,  which  led 
to  the  invention  and  employment  of  a  decalcified  bone  bobbin 
to  act  as  a  temporary  splint,  over  which  to  apply  the  sutures, 
and  thus  to  secure  a  large  aperture  which  has  little  tendency  to 
contract. 

Am  Surg  13 


194  ROBSON, 

Gastro-enterostomy ,  in  the  absence  of  special  complications,  is 
the  operation  to  be  relied  on  in  the  treatment  of  ulcer  of  the 
stomach.  It  acts  by  securing  physiological  rest  by  means  of 
drainage,  thus  allowing  the  ulcer  to  heal  without  being  subjected 
to  the  irritation  of  acid  secretion,  accumulation  of  food  or  fre- 
quent stomach  movement.  It  also,  while  remedying  the  hyper- 
chlorhydria,  relieves  pyloric  spasm,  and  while  preventing  stagna- 
tion of  fermenting  fluids  materially  diminishes  gastric  dilatation. 
The  posterior  operation  is  the  one  I  personally  prefer,  the  junc- 
tion of  the  posterior  wall  of  the  stomach  with  the  first  part  of 
the  jejunum  being  effected  by  two  continuous  sutures  with  or 
without  a  decalcified  bone  bobbin. 

The  use  of  a  bone  bobbin  not  only  secures  an  ample  and  im- 
mediately patent  opening  between  the  two  viscera  for  the  pass- 
age of  the  stomach  contents,  but  protects  the  line  of  union  from 
the  irritation  of  the  stomach  contents. 

The  whole  operation  can  be  easily  completed  in  half  an  hour, 
and  it  may  even  be  done  in  half  the  time.  Along  with  my  col- 
league, Mr.  Moynihan,  I  have  given  my  full  experience  of  the 
operation  and  of  stomach  surgery  in  general,  in  book  form,  now 
in  the  hands  of  the  publishers,  Messrs.  Balliere,  Tindall  &  Cox. 

Our  experience  with  the  posterior  operation  has  been  very 
favorable,  not  only  in  the  rate  of  the  recovery  of  the  patients, 
but  in  the  smoothness  of  the  recovery,  many  of  the  patients 
recovering  without  even  once  vomiting,  and  only  on  two  occa- 
sions have  we  seen  regurgitant  vomiting  of  bile,  which,  in  the 
anterior  operation,  is  much  more  frequently  seen,  and  at  times 
becomes  serious,  or  even  leads  to  a  fatal  issue. 

We  have  performed  the  posterior  operation  on  forty  patients, 
with  two  deaths,  or  an  average  mortality  of  5  per  cent,  but 
as  the  deaths  were  from  more  or  less  accidental  causes,  which 
should  be  avoided  in  the  future,  and  occurred,  respectively,  on 
the  tenth  and  eleventh  days  after  operation,  during  the  whole  of 
which  time  the  patients  had  been  able  to  take  and  assimilate  food, 
the  gastro-enterostomy,  per  se,  cannot  be  blamed  for  the  result, 
and  which  might,  under  similar  circumstances,  have  occurred 
after  any  operation. 


CHRONIC    ULCER    OF    THE    STOMACH.  I95 

Dr.  Fantino  ^  examined  Professor  Carle's  cases  of  gastro- 
enterostomy as  regards  the  following  points : 

1.  Changes  in  the  peristalsis  of  the  stomach. 

2.  The  ability  or  non-ability  of  the  new  sphincters  to  close 
the  outlet. 

3.  The  capacity  of  the  stomach. 

4.  The  secretion  of  hydrochloric  acid. 

In  the  cases  examined  the  operation  immediately  improved 
the  peristaltic  power  of  the  stomach,  though  it  did  not  render 
it  normal.  The  stomach  could  generally  empty  itself,  but  did 
so  gradually.  Systematic  examinations  of  the  stomach  con- 
tents were  made  after  test-meals,  etc.,  and  showed  that  after  an 
irregular  period  the  stomach  regained  completely  its  power  of 
emptying  itself;  in  fact,  as  a  rule,  after  gastro-enterostomy  the 
stomach  would  be  found  practically  empty  in  three  to  five  hours 
after  a  meal.  Generally,  it  was  found  that  the  stomach  decreased 
in  size  soon  after  gastro-enterostomy,  so  that  the  formerly  dis- 
tended organ  became  normal  in  size.  Examinations  of  the 
stomach  by  means  of  distention  with  carbonic  acid  and  by  other 
methods  showed  that  a  sphincter  was  developed  at  the  new 
opening,  and  that  its  power  increased  with  time. 

The  secretion  of  hydrochloric  acid  after  operation  was 
studied : 

In  cases  where  there  was  formerly  hyperacidity  this  condi- 
tion was  lost,  and  though  the  degree  of  acidity  in  any  indi- 
vidual case  varied  from  time  to  time,  yet  these  variations  did 
not  depart  from  physiological  limits.  In  the  same  examinations" 
it  was  found  that  regurgitation  of  bile  into  the  stomach  took 
place,  but  it  was  of  no  importance  so  long  as  the  outlet  from 
the  organ  was  sufficient. 

Cases  of  hypo-  and  anacidity  showed  no  change  in  their 
gastric  juice  after  operation,  showing  clearly  that  this  condition 
is  not  dependent  on  obstruction,  but  on  previous  changes  in  the 
mucous  membranes,  these  changes  being  probably  in  the 
nature  of  an  atrophy  of  the  peptogastric  glands. 

1  Archiv  fiir  klinische  Chirurgie,  xlix.,  i  and  2. 


196  ROBSON, 

The  following  cases  are  given  as  examples  of  the  treatment 
of  gastric  ulcer  by  gastro-enterostomy. 

Case  I. — Mrs.  W.,  aged  thirty-two  years.  Pyloric  ulcer,  treated  by 
pyloroplasty,  with  subsequent  contraction,  Gastro-enterostomy — 
pyloroplasty,  during  active  ulceration  of  pylorus,  in  December,  1895, 
Great  relief  for  a  time,  but  later  recurrence  of  dilatation,  vomiting, 
pain,  and  other  symptoms.  Very  considerable  loss  of  flesh.  Patient 
thin  and  anaemic ;  pulse  feeble  and  rapid,  marked  dilatation,  the 
stomach  reaching  well  below  the  umbilicus. 

October  10,  1898,  Operation.  Gastro-enterostomy  (bone  bobbin 
employed).  In  October,  1899,  patient  well  and  active.  February, 
1900,  had  gained  i  stone  10  pounds. 

Case  II, — Mr.  M.  A.,  aged  twenty-eight  years.  Pyloric  ulcer; 
tumor  of  pylorus ;  gastro-enterostomy.  Two  years  ago  was  1 2  stone 
12  pounds,  now  9  stone  6  pounds.  Pain  two  hours  after  food.  For 
last  two  months  vomiting  on  an  average  five  times  a  week,  twice 
coffee-ground  vomit.  Enormous  dilatation  of  stomach.  Pyloric 
tumor  movable,  visible  peristalsis. 

August  4,  1899.  Operation.  Large  mass  at  pylorus,  evidently 
thickening,  due  to  ulceration ;  glands  large,  but  not  matted.  Gastro- 
enterostomy (bone  bobbin  used). 

2']th.     Good  recovery.     Weight,  9  stone  7  pounds, 

September  20th.  Weight,  10  stone  13  pounds.  Can  eat  anything. 
Well,  1 90 1. 

Case  III. — Mr.  D.  B.,  aged  thirty-one  years.  Extensive  ulceration 
of  stomach,  with  large  tumor.  Gastro-enterostomy  (anterior). 
Dyspepsia  seventeen  years.  More  severe  last  twenty  months.  Six- 
teen months  ago  vomiting  recurred,  and  from  outset  large  quantities 
ejected,  but  never  containing  blood.  Recurrence  occasionally  of 
similar  attacks,  always  relieved  by  treatment. 

December,  1897,  stomach  reached  pubes,  and  visible  peristalsis  seen. 
Relief  followed  dieting  and  lavage  till  March,  1898,  since  which  time 
pain  almost  constant.  Pain  not  materially  worse  after  food,  nor 
relieved  by  vomiting.  Loss  of  weight  from  10  stone  to  8  stone  6^ 
pounds.     Great  feebleness. 

May  6,  1898.  Operation.  Large  irregular  tumor  at  pylorus  and 
along  lesser  curvature,  but  glands,  though  large,  discrete.  Gastro- 
enterostomy (bone  bobbin  employed).  Eight  stone  in  weight  when 
he  left  the  home,  July  7,  1898, 


CHRONIC    ULCER    OF    THE    STOMACH.  I97 

August  \ith.  Weighs  9  stone  3  pounds.  Letter  dated  February 
12,  1900,  to  say:  "  My  health  continues  perfect.  I  have  not  lost  a 
day's  work  through  illness  since  I  recovered." 

Case  IV. — Miss  H,,  aged  thirty-two  years,  sent  to  me  with  a  history 
of  stomach  symptoms  extending  over  several  years.  She  had  had 
haematemesis  in  1S92  and  1896,  since  which  time  she  had  suffered 
from  flatulency  and  pain  after  food.  For  two  years  epigastric  pain 
constant,  but  increased  by  food.  A  year  ago  vomited  daily,  then 
relief  for  a  time,  but  for  some  months  only  milk  could  be  retained. 
Epigastric  tenderness  was  well  marked,  and  on  distending  the  stomach 
with  CO2  it  reached  half  an  inch  below  the  umbilicus  and  far  over 
to  the  right  of  the  middle  line. 

October 'i^,  1900.  Posterior  gastro-enterostomy  performed,  a  bone 
bobbin  being  employed. 

Recovery  uninterrupted.  Returned  home  within  the  month,  taking 
solid  food  without  any  discomfort,  and  gaining  flesh. 

On  November  8th  Dr.  A.  writes:  "I  have'  seen  Miss  H.  since  her 
return,  and  there  is  every  reason  to  be  pleased  with  her  condition. 
She  has  lost  all  her  pain,  and  is  taking  food  well.  Allow  me  to  thank 
you  for  her  restoration  to  comparative  health." 

Report  of  weight  February  i,  1901,  8  stone  6  pounds;  at  time  of 
operation,  6  stone  12  pounds. 

Case  V. — Mr.  H.,  aged  fifty-two  years,  began  to  suffer  in  1897  from 
symptoms  of  ulcer  of  stomach,  which  were  relieved  by  restricted  diet 
and  general  treatment,  but  in  July,  1899,  the  symptoms  returned,  with 
great  loss  of  flesh  and  strength.  Well-marked  dilatation  of  the  stomach 
was  discovered  and  operative  treatment  advised. 

Lavage  and  other  treatment  was  carried  out  in  London  and  in  Scot- 
land, but  without  material  improvement. 

When  first  seen  by  me  there  was  visible  peristalsis,  with  well-marked 
stomach  splash  and  a  tender  spot  under  the  right  costal  margin.  Al- 
though tall,  the  patient  only  weighed  8  stone  10  pounds,  and  he  was 
extremely  weak  and  pallid. 

October  12,  1900.  Operation.  Hour-glass  stomach  found,  but  the 
stricture  was  not  extreme.  Puckering  on  anterior  wall  of  the  stdmach, 
with  well-marked  thickening.  Free  HCl  discovered  in  the  stomach 
contents. 

Posterior  gastro-enterostomy  performed.     Good  recovery. 

March  ^,  1901.  Patient  wrote  from  Bournemouth  saying :  "I  am 
pleased  to  be  able  to  tell  you  that  I  have  had  no  return  of  my  former 


198  ROB  SON, 

complaint,  and  that  I  eat,  drink,  and  sleep  well.  Have  got  back  to 
my  former  weight. 

Case  VI. — History.  J.  S.,  aged  forty-five  years,  residing  at  Batley  ; 
gave  the  history  of  two  years'  pain  about  an  hour  after  food,  with  great 
loss  of  flesh.  For  nine  months  he  had  vomited  every  day  or  every 
second  day  a  large  quantity  of  yeasty  material,  but  no  blood,  though 
he  was  very  anaemic. 

There  were  well-marked  signs  of  dilatation,  with  tenderness  over 
the  pylorus. 

lune  12,  1900.  Operation.  On  opening  the  abdomen  the  pylorus 
was  much  thickened  and  adherent,  forming  a  tumor,  and  through  the 
centre  of  the  mass  a  No.  10  catheter  could  only  be  passed,  over  a 
roughened,  ulcerated  surface.  A  posterior  gastro-enterostomy  was 
performed . 

After-history.  An  uninterrupted  recovery  followed.  Food  was 
begun  the  second  day,  and  solids  could  be  taken  in  the  second  week 
without  pain.     He  rapidly  gained  flesh  and  strength,  and  is  now  well. 

The  following  case  illustrates  the  value  of  gastro-enterostomy 
in  acute  haematemesis. 

Chronic  ulcers  ;  hczmatetnesis  ;  gastro-enterostomy.  Mr.  F.,  a  farmer, 
residing  in  Essex,  was  sent  to  me  by  Dr.  A.  J.  T.  White,  on  March  25, 
1901,  and  he  kindly  furnished  the  following  history  : 

"  I  first  saw  Mr.  F.  five  years  ago ;  he  had  then  occasional  pain  in 
the  epigastrium,  with  much  flatulence,  and  at  times  vomiting.  This 
kept  on  at  intervals  more  or  less  for  three  years.  Eighteen  months  ago 
Dr.  G.  saw  him  with  me.  At  that  time,  instead  of  his  former  weight 
of  16  stone,  he  only  turned  the  scale  at  12  stone.  He  then  improved 
gradually  for  about  three  months,  and  gained  about  a  stone  in  weight. 
Six  months  later,  or  about  a  year  ago,  he,  while  out  driving,  had  some 
abdominal  pain,  and  vomited  considerable  quantities  of  blood.  He 
continued  being  sick  and  suff"ering  for  some  time,  with  slight  haema- 
temesis and  meljena,  but  again  improved.  About  three  or  four  months 
ago  he  got  worse,  and  has  been  vomiting  and  suffering  considerable 
pain  on  and  off  ever  since.  I  have  very  little  doubt  but  that  this 
original  trouble  was  gastric  ulcer,  but  my  fear  now  is  lest  malignant 
ulceration  should  have  supervened,  and  some  time  ago  I  asked  him  to 
see  you.     He  could  not  go  then,  as  he  had  various  business  matters  to 


CHRONIC    ULCER    OF    THE    STOMACH.  I99 

set  right,  but  now  is  willing.  He  is  a  man  of  iron  will  and  constitu- 
tion, though  terribly  pulled  down." 

On  Mr.  F.'s  arrival  in  Leeds  he  went  direct  to  a  surgical  home, 
his  weight  then  being  10  stone.  He  was  suffering  severe  pain,  but 
was  able  to  take  a  little  milk,  which  was,  in  fact,  the  only  form  of  food 
he  had  been  able  to  digest  for  a  long  time.  Within  a  few  hours  he  was 
seized  with  violent  hsematemesis  and  vomited  five  pints  of  clots  and 
dark  fluid  mixed  with  mucus.  Rectal  feeding  was  at  once  adopted, 
and  an  ice  bag  applied  to  the  epigastrium.  The  next  day  much  coffee- 
ground  material  was  vomited,  and  on  the  third  day  the  bleeding  ceased. 
An  operation,  which  was  clearly  demanded,  was  arranged  for  March 
22d,  but  on  the  night  of  the  21st  he  again  vomited  two  pewters  full  of 
pure,  dark  blood,  which  clotted  soon  after  being  vomited.  The  stomach 
was  quite  empty  of  food,  as  after  the  night  of  his  admission  feeding 
had  been  entirely  rectal.  He  was  now  extremely  weak ;  but  as  the 
vomiting  and  bleeding  were  continuing.  Dr.  White  agreed  with  me 
that  it  would  be  better  not  to  postpone  operation,  for  he  was  rapidly 
losing  ground,  and  clearly  could  not  stand  a  greater  loss.  An  hour 
before  operation  he  vomited  blood  freely  again. 

On  the  morning  of  March  22d,  on  opening  the  abdomen,  the  lesser 
curvature  of  the  stomach  was  found  to  be  much  indurated,  forming  a 
tumor.  There  was  also  much  puckering  of  the  surface  of  the  stomach, 
and  the  glands  in  the  greater  and  lesser  omentum  were  enlarged,  but 
discrete.  A  posterior  gastro-enterostomy  was  performed,  a  bone  bob- 
bin being  used.  In  order  to  guard  against  shock  he  was  enveloped  in 
cotton-wool;  had  ten  minims  of  liq.  strychnise,  B.  P.,  given  sub- 
cutaneously  before  operation,  and  had  a  pint  of  saline  fluid,  with  an 
ounce  of  brandy,  given  into  the  bowel.  Immediately  after  operation, 
which  was  finished  within  the  half  hour,  nearly  a  pint  of  saline  fluid 
was  injected  into  the  subcutaneous  tissues  of  the  axilla,  and  another 
pint,  together  with  an  ounce  of  brandy,  administered  per  rectum. 
During  the  day  three  injections,  of  five  minims  of  liq.  strychnise, 
were  given,  and  the  rectal  enemata  were  repeated. 

Very  little  shock  was  felt,  and  the  after-progress  was  uninterrupted. 
The  bowels  were  moved  on  the  third  day,  and  the  wound  was  dressed 
and  found  healed  on  the  tenth.  No  more  blood  was  parted  with,  and 
stomach-feeding  was  begun  four  days  after  operation.  By  the  end  of 
the  week  he  was  taking  as  much  as  five  pints  of  fluid  nourishment  in 
the  twenty-four  hours.  He  said  he  had  never  had  any  pain  since  the 
operation,  and  was  feeling  better  than  he  had  done  for  a  long  time. 


200  R  O  B  S  O  N  , 

He  had  lost  all  the  acid  eructations,  the  constant  burning  at  the  epi- 
gastrium, and  the  flatulency.  He  returned  home  within  the  month 
very  well,  and,  as  showing  the  state  of  his  digestion,  he  had  gained 
4  pounds  in  the  week  before  he  left  the  surgical  home. 

Pyloroplasty ,  as  a  curative  measure  in  this  class  of  cases,  has 
certain  very  definite  limitations,  but  where  it  is  feasible  it  is  a 
method  of  great  utility,  which  can  be  performed  rapidly  and 
with  very  little  exposure  of  viscera.  Pyloroplasty,  if  the  pylorus 
be  stenosed,  free  from  extensive  adhesions,  easily  drawn  for- 
ward, and  not  actively  ulcerating,  is  a  simple  and  short  opera- 
tion, and  in  quite  a  number  of  cases,  of  both  gastric  and  pyloric 
ulcer,  I  have  found  it  to  answer  well.  It  must  not  be  relied  on, 
however,  where  active  ulceration  of  the  pylorus  itself  is  found, 
unless  at  the  same  time  the  ulcer  be  completely  excised ;  other- 
wise cicatricial  contraction  will  follow.  It  acts  in  the  same  way 
as  does  gastro-enterostomy — by  affording  a  free  exit  to  the 
stomach  contents,  and  thus  securing  physiological  rest  to  the 
stomach. 

The  histories  to  be  related  exemplify  the  complete  success 
which  attended  the  operation  in  appropriate  cases,  and  also  the 
disappointment  which  followed  its  employment  in  one  of  the 
earlier  examples,  which,  owing  to  inexperience,  was  not  properly 
selected. 

Professor  Carle  and  Fantino'  compare  the  operation  of  gastro- 
enterostomy and  pyloroplasty.  Out  of  14  cases  in  which  the 
latter  operation  was  performed,  only  i  died. 

The  results  of  pyloroplasty,  as  regards  function,  have  been 
little  noticed  in  literature.  To  the  author's  14  cases,  3  may  be 
added  where  the  operation  was  by  tearing,  but  the  results  were 
the  same.  In  all  the  17  cases  the  results  were  excellent;  in  13 
of  them  perfect  and  permanent,  as  it  is  now  from  three  to  seven 
years  since  operation.  In  these  the  condition  of  the  secretions 
and  of  the  peristaltic  power  of  the  stomach  was  the  same  as 
after  gastro-enterostomy  for  non-malignant  stenosis.  Diminu- 
tion in  size  of  the  stomach  was  not  so  marked  as  would  be  ex- 

'  Loc.  cit. 


CHRONIC    ULCER    OF    THE    STOMACH.  2C I 

pected  in  the  presence  of  such  remarkable  recovery  of  the  gen- 
eral health  and  of  the  stomach's  power  to  empty  itself.  In  all 
cases,  with  one  exception,  the  gastric  capacity  was  more  or  less 
diminished;  but  in  no  case  did  it  become  normal  in  size. 

A  few  cases  must  be  excepted  where  operation  was  performed 
for  hyperacidity  with  gastric  atony.  In  these,  four  or  five  months 
after  operation,  there  was  delayed  evacuation  of  the  stomach  and 
a  feeling  of  weight.  Although  the  general  improvement  was 
considerable,  yet  the  authors  were  persuaded  that  a  posterior 
gastro-enterostomy  would  have  given  better  results.  In  one  of 
the  cases  a  subsequent  gastro-enterostomy  gave  a  perfect  re- 
covery. 

In  cases  where  there  was  hyperacidity  before  the  operation 
there  was  a  rapid  return  to  the  normal,  but  not  to  below  normal, 
as  was  found  after  gastro-enterostomy.  The  authors  believe 
that  the  rapid  and  great  diminution  in  hydrochloric  acid  after 
the  latter  operation  is  due  to  the  very  rapid  evacuation  of  the 
stomach  after  a  meal,  and  do  not  deny  the  possible  influence  of 
a  regurgitation  of  bile  into  the  stomach.  Both  these  conditions 
are  absent  after  pyloroplasty,  hence  the  difference  in  secretion. 
In  cases  of  hypo-  and  anacidity,  operation  produced  no  change 
in  this  particular,  and  yet  health  was  restored.  The  results  of 
pyloroplasty  may  be  summarized  : 

1.  Regurgitation  of  bile  into  the  stomach  is  prevented. 

2.  Secretion  of  hydrochloric  acid,  when  it  has  been  exces- 
sive, becomes  normal. 

3.  If  the  secretion  of  hydrochloric  acid  has  been  diminished 
or  absent  before  operation,  it  remains  in  statu  quo  after  opera- 
tion. 

4.  If  there  has  been  primary  gastric  atony,  peristalsis  is  but 
little  improved. 

5.  This  function  improves  rapidly  or  reaches  perfection  if  the 
muscular  contractility  has  been  normal  or  increased,  and  when 
the  obstruction  was  due  to  fibrous  stenosis  or  pyloric  spasm. 

6.  In  all  such  cases  evacuation  of  the  stomach  is  accomplished 
in  its  physiological  period.  Only  in  rare  cases,  and  these  only 
in  the  first  months  after  operation,  may  it  be  delayed. 


202  R  O  B  S  O  N , 

7.  The  capacity  of  the  stomach  always  decreases,  but  rarely 
becomes  as  small  as  normal. 

8.  The  pylorus  recovers  tone. 

Points  of  difference  between  the  results  of  pyloroplasty  and 
gastro-enterostomy  are  : 

1.  The  absence  of  regurgitation  of  bile,  and  hence  the  absence 
of  any  possible  biliary  influence  on  the  gastric  secretions. 

2.  The  evacuation  of  the  stomach  is  not  accelerated,  hence  the 
difficulty  the  stomach  has  in  reaching  its  normal  size. 

3.  The  slight  or  negative  result  obtained  by  pyloroplasty  in 
obstruction  from  primary  gastric  atony  compared  to  the  posi- 
tive results  from  posterior  gastro-enterostomy. 

Pyloroplasty  is  too  dangerous  in  cases  where  there  is  exten- 
sive induration  of  the  tissues,  much  peripyloritis  and  adhesions 
to  liver,  gall-bladder,  colon,  etc.,  and  in  cases  of  duodenal 
stenosis. 

It  is  indicated  in  cases  of  spasmodic  stenosis  and  in  slight 
annular  stenosis  from  ulceration  accompanied  by  muscular  hyper- 
trophy. 

Statistics.  In  the  Hunterian  Lectures  I  collected  318  cases  of 
pyloroplasty  from  all  sources,  of  which  269  recovered,  which 
equals  a  mortality  of  15.4  per  cent.  This  included  14  cases  of 
the  lecturers,  of  which  12  recovered,  a  mortality  of  14.2  per  cent. 
As  in  the  earlier  operations,  many  were  performed  on  cases  that 
would  be  now  treated  by  gastro-enterostomy.  The  mortality 
in  properly  selected  cases  should  not  exceed  5  per  cent,  at  the 
outside  estimate,  and  of  the  12  cases  I  have  operated  on  since 
1897  there  is  no  fatality  to  record. 

Case  I. — March  9,  1895.  Mrs.  W.,  aged  twenty-nine  years.  Had 
"spasms"  for  ten  years,  but  pain  more  on  left  side.  Attacks  two  or 
three  times  a  week;  start  without  apparent  reason,  last  an  hour  or 
two,  but  may  persist  twenty-four  hours  ;  relieved  by  vomiting.  Severe 
cramps  in  legs  ;  loss  of  2  stones  in  weight  :  no  jaundice  \  marked  con- 
stipation ;  rigid  right  rectus;  no  rigidity,  but  tenderness  to  left ;  dila- 
tation of  stomach  well  marked. 

November  22,  1895.  Relief  under  treatment,  followed  by  relapse  ; 
now  vomiting  daily.     Weight,  9  stone. 


CHRONIC    ULCER    OF    THE    STOMACH.  2O3 

Operation.  Adhesions  of  pylorus  separated.  Active  ulceration  at 
pylorus  and  tight  stricture.     Pyloroplasty  (bone  bobbin). 

July  24,  1896.  Weight,  9  stone  5  pounds.  Very  much  better. 
Relapse  in  189S,  possibly  from  recurrence  of  ulceration.  I  then  per- 
formed gastro-enterostomy.  Quite  well  in  1900,  and  former  weight 
fully  regained. 

Case  II. — January  13,  1897.  Mr.  M.  B.,  aged  fifty-two  years. 
Ulcer  of  pylorus,  with  stricture.  Pyloroplasty.  Bad  health  for  twenty 
years,  with  dyspepsia;  worse  since  enteric  fever,  nine  years  ago.  Last 
two  years  much  worse ;  pain,  sickness,  and  vomiting  two  to  three 
hours  after  meals,  relieved  by  vomiting  of  large  amounts;  never 
vomited  blood ;  loss  of  flesh.  Weight,  9  stone  3  pounds.  Emacia- 
tion, dilatation  of  stomach;  no  tumor. 

Operation.     Stricture  of  pylorus.    Pyloroplasty  (bone  bobbin  used). 

September  19,  1898.  Dr.  W.  writes :  "For  some  time  little  im- 
provement ;  stomach  now  works  well.  Looks  better  than  I  have  ever 
seen  him." 

Well  February,  1901.     Had  gained  normal  weight. 

Case  IIL— March  18,  1897.  Mrs.  W.,  aged  forty-six  years.  Stric- 
ture, with  active  ulceration  at  pylorus  Pyloroplasty.  Gastralgia  for 
several  years  relieved  by  food. 

In  November,  1894,  vomited  dark  fluid;  since  then  frequent  vomit- 
ing ;  longest  interval  two  or  three  weeks.  Pain  in  stomach,  accom- 
panied by  hard  lump,  and  often  followed  by  vomiting.  Great  loss  of 
flesh  and  strength. 

Operation.  Pyloroplasty  for  contraction  and  thickening  of  pylorus ; 
passage  only  admitted  No.  2  catheter.     Good  recovery. 

Well  1899.     Considerable  gain  in  weight. 

Case  IV. — May  24,  1897.  Mr.  H.,  aged  thirty-nine  years.  Letter 
dated  May  13,  1897,  to  say:  "  During  the  last  eighteen  months  I  have 
suff'ered  much  pain,  which  has  caused  me  to  be  bedfast  for  two,  three, 
or  four  weeks  at  a  time,  and  it  has  required  another  month  or  more  for 
me  to  gain  strength  enough  to  move  about."  Eighteen  months  ago 
epigastric  pain  several  hours  after  food  ;  relieved  by  vomiting.  Since 
then  health  never  good.  Three  and  a  half  months  ago  similar  attack  ; 
very  severe,  with  collapse.  Vomit  contained  blood.  Fourteen  days 
ago  another  severe  attack.  Normal  weight,  10  stone  10  pounds; 
now,  9  stone  t,]4  pounds.  Stomach  ''weak"  since  childhood. 
Marked  dilatation.     No  tumor. 

Operation.     Deep  ulcer  at  pylorus.     Extreme  stricture,  barely  ad- 


204  R  O  B  S  O  N  , 

mitting  ordinary  director.      Pyloroplasty  (bone  bobbin  used).     Com- 
plete recovery  from  operation,  and  rapidly  regained  normal  weight. 

Letter  dated  February  i6,  1898,  to  say  :  "  I  thought  you  would  like 
to  know  that  I  am  able  to  attend  to  business  as  usual,  and  have  done 
so  without  interruption  since  July  19,  1897." 

Case  V. — July  12,  1S97.  Mrs.  W.,  aged  forty-six  years.  Said  to 
have  had  ulcer  of  stomach  twenty  years  ago.  Since  then  subject  to 
attacks  of  pain  one-half  to  two  hours  after  food  ;  sometimes  continu- 
ous pain.  For  three  or  four  months  vomited  three  times  a  day.  Lost 
a  stone  weight  in  that  time.  Leading  life  of  an  invalid,  and  for  a 
long  period  under  medical  treatment  without  benefit.  Dilatation  of 
stomach;  visible  peristalsis;  tenderness  over  stomach,  especially  at 
the  pylorus.     No  tumor  could  be  felt. 

Operation.     Stomach  much  dilated  ;  thickening  at  pylorus.    Pyloro- 
plasty (bone  bobbin  used).     Good  recovery. 
January  8,  1898.     Weighed  11  stone,  a  gain  of  over  2  stone. 

Case  VI. — July  27,  1S97.  Mr.  C,  aged  twenty-three  years. 
Vomiting  and  loss  of  flesh  for  two  years.  Once  was  10  stone;  now 
is  7  stone  in  weight.  Dieting  and  lavage  gave  only  temporary  relief. 
Emaciation,  pallor,  and  dilatation  of  stomach.     No  tumor. 

Operation.  Much-contracted  pylorus;  great  hypertrophy,  the  walls 
being  more  than  one-third  of  an  inch  in  thickness.  Pyloroplasty,  with 
bone  bobbin.     Good  recovery. 

December  23,  1897.     Weight,  9  stone  13  pounds.     Well. 

Case  VII. — W.  F.,  aged  fifty-two  years,  had  suffered  from  indiges- 
tion for  two  years.  This,  however,  had  not  interfered  much  with  his 
general  health  till  the  previous  Christmas,  when  the  indigestion  was 
accompanied  every  second  day  by  acute  pain  and  vomiting,  coming 
on  about  two  hours  after  food.  The  vomited  matter  was  in  large 
quantity,  offensive,  and  sour,  and  at  times  coffee-ground  in  character. 
From  this  time  the  patient  became  extremely  weak  and  pale,  and 
rapidly  lost  flesh  to  the  extent  of  i  stone  7  pounds  in  five  weeks. 
He  had  pain  on  pressure  over  the  pylorus;  but  no  distinct  tumor  was 
felt.  There  was  marked  dilatation  of  the  stomach,  and  during  the 
attacks  of  pain  it  could  be  felt  to  harden  under  the  hand. 

On  April  8,  1895,  the  abdomen  was  opened  by  an  incision  in  the 
middle  line  above  the  umbilicus,  exposing  the  pylorus,  which  formed 
a  distinct  tumor,  adherent  to  and  under  cover  of  the  liver,  and  which, 
after  being  freed  from  adhesions  to  surrounding  structures,  was  found 
to  be  tightly  strictured,  so  as  only  to  admit  the  passage  of  a  No.  12 


CHRONIC    ULCER    OF    THE    STOMACH.  205 

catheter ;  the  mucous  membrane  being  extensively  ulcerated,  and  the 
walls  thick  and  almost  cartilaginous.  The  stricture  was  incised  longi- 
tudinally and  sutured  transversely  over  a  bone  bobbin  by  a  double 
row  of  sutures.  The  stomach  was  much  dilated  and  atonic.  Though 
the  pyloric  tumor  gave  rise  at  the  moment  to  a  suspicion  of  cancer, 
there  was  no  evidence  of  growth,  and  the  glands  were  not  affected. 

October  30,  1S96,  he  called  to  report  himself,  looking  robust  and 
well.     He  had  gained  3  stone  in  weight  since  his  operation. 

Gastroplasty  is  an  operation  that  I  have  successfully  employed 
in  a  number  of  cases  of  chronic  ulcer  leading  to  hour-glass 
stomach.  It  consists  in  making  a  longitudinal  incision  through 
the  strictured  part  of  the  stomach  and  bringing  the  edges  of  the 
wound  together  transversely,  thus  obliterating  the  stricture. 

A  convenient  method  of  performing  the  operation  is  by  the 
use  of  a  large  decalcified  bone  bobbin  as  described  in  the  cases 
appended.  If  the  strictured  part  of  the  stomach  be  actively 
ulcerating  the  ulcer  must  be  excised  at  the  same  time,  other- 
wise subsequent  contraction  may  occur,  or  possibly  the  ulcer, 
already  chronic,  may  persist  and  lead  to  a  continuance  of  the 
symptoms;  in  such  a  case,  if  excision  be  impracticable,  gastro- 
enterostomy must  be  performed,  or  if  the  pylorus  be  free  from 
disease  the  operation  oi gastrogastrostomy  may  be  done  in  order 
to  short-circuit  the  constriction, 

I  have  operated  on  13  cases  of  hour-glass  stomach  due  to 
chronic  ulcer,  with  12  recoveries.  The  following  are  good 
examples  : 

Case  I. — M.  B.,  aged  twenty-nine  years,  gave  a  four-years'  history  of 
ulceration  of  the  stomach,  with  vomiting  of  blood  on  one  occasion,  and 
the  presence  of  melaena  several  times.  As  the  pain  was  always  easier 
when  the  patient  was  lying  on  the  back,  an  ulcer  on  the  anterior  sur- 
face of  the  stomach  was  diagnosed. 

This  was  confirmed  at  the  operation,  as  the  anterior  wall  of  the 
stomach  was  so  puckered  that  the  cavity  was  divided  into  two,  which 
were  connected  by  a  narrow  channel,  which  was  laid  open  by  a  free 
longitudinal  incision,  in  which  was  laid  a  large  bone  bobbin,  the 
wound  being  then  brought  together  transversely  over  it,  thus  leaving 
a  channel  of  nearly  two  inches  between  the  two  cavities.     The  patient 


2o6  ROB  SON, 

went  home  within  the  month,  and  has  completely  recovered  her  health 
and  strength. 

Case  II. — Mr.  D.  M.,  aged  forty-four  years,  admitted  with  well- 
marked  dilatation  of  the  stomach,  and  a  history  of  twenty  years'  gas- 
tric trouble. 

The  constriction  in  this  case  was  two  and  a  half  inches  from  the 
pylorus,  the  cavity  between  the  stricture  and  the  pylorus  being  very 
much  smaller  than  the  proximal  one.  The  treatment  was  by  gastro- 
plasty over  a  large  bone  bobbin. 

Recovery  was  delayed  by  an  attack  of  pleurisy,  but  the  patient  is 
now  quite  well,  and  has  gained  rapidly  in  weight. 

Case  III.  Double  hour-glass  contraction  of  the  stomach.  Gastro- 
plasty and  gastrolysis. — Miss  M.  P.,  aged  thirty  years.  There  had 
been  attacks  of  pain  and  vomiting  for  fifteen  years.  The  pain  began 
at  the  left  side  and  passed  to  the  epigastrium  and  through  to  the  left 
subscapular  region.  There  had  been  severe  haematemesis  ten  years 
before.  Occasionally,  both  before  and  since,  the  vomit  had  been 
streaked  with  blood,  which  was  sometimes  "coffee-ground,"  but  it 
had  contained  no  large  quantity  of  blood  for  eight  years.  The  patient 
vomited  large  quantities  at  times  and  had  lost  flesh  steadily  for  the  last 
five  years.  There  were  dilatation  of  the  stomach  and  peristalsis.  No 
tumor  could  be  felt,  but  the  pylorus  was  felt  to  harden  from  time  to 
time. 

Operatio7i,  June  6,  1899,  at  a  surgical  home  in  Leeds.  Double- 
hour  glass  contraction  discovered.  One-third  of  the  distance  from  the 
cardiac  extremity  adhesions  caused  a  marked  diminution  of  calibre, 
and  two  inches  from  the  pylorus  a  contraction  only  admitting  the  tip 
of  the  little  finger  was  found.  The  adhesions  were  divided  and  gas- 
troplasty was  performed,  the  wound  being  sutured  over  a  large  bone 
bobbin. 

After-history. — The  patient  made  an  uninterrupted  recovery,  and 
in  two  months  she  had  gained  2  stone  in  weight. 

Case  IV.  Extreme  hour-glvs  contraction.  Gastroplasty. — Miss  M. 
D.,  aged  forty-eight  years.  The  patient  had  had  constant  indigestion 
and  flatulence  for  twenty  years,  with  a  feeling  of  pulsation  and  tender- 
ness at  the  epigastrium.  There  had  been  free  hsematemesis  two  years 
before  and  vomiting  occasionally  since,  but  lately  the  patient  had 
ceased  to  take  much  solid  food.  She  had  noticed  slime  and  blood 
in  the  motions,  possibly  due  to  constipation,  which  was  extreme. 
There  had  been  great  loss  of  flesh.     No  tumor  was  present,  but  there 


CHRONIC    ULCER    OF    THE    STOMACH.  20/ 

was  tenderness  in  the  epigastrium  and  a  well-marked  splash  on  succus- 
sion. 

Operation,  July  28,  1899.  Extreme  contraction  one-third  way  from 
pylorus,  just  admitted  tip  of  little  finger.  Gastroplasty  was  performed, 
a  large  bone  bobbin  being  used. 

After-hislory.  The  patient  made  a  good  recovery  from  the  opera- 
tion and  the  indigestion  was  relieved.  There  was  an  increase  in 
weight  of  about  a  stone,  and  improvement  in  the  general  health,  but 
the  stomach  remained  dilated,  and  she  continued  anaemic  and  weak  ; 
this  was  at  first  thought  to  be  due  to  bleeding  from  piles,  but  after  they 
had  been  ligatured  the  weakness  still  continued,  and,  although  there 
was  no  vomiting,  flatulency  and  discomfort  after  meals,  with  loss  of 
appetite,  led  to  a  suspicion  of  recurrence  of  disease  in  the  stomach, 
which  on  being  distended  with  CO,  reached  three  inches  below  the 
umbilicus,  and  on  being  washed  out  after  a  test-meal  showed  impaired 
motility. 

January  24,  1901.  The  abdomen  was  6pened  again  through  a 
medium  incision  above  the  umbilicus,  when  marked  dilatation  of  the 
stomach  was  seen,  with  contraction  and  some  thickening  over  the 
pylorus  ;  but  where  the  hour-glass  contraction  had  been  operated  on 
eighteen  months  previously,  it  was  interesting  to  note  that  neither  scar- 
ring nor  contraction  was  seen,  and  it  would  have  been  impossible  to 
tell  by  naked-eye  appearances  that  anything  had  been  done. 

A  posterior  gastro-enterostomy  was  performed,  a  bone  bobbin  being 
employed.  Recovery  was  uninterrupted,  and  before  the  patient  left 
the  home,  at  the  end  of  the  month,  she  was  taking  ordinary  food  with 
relish  and  without  any  discomfort.  She  had  then  gained  several 
pounds  in  weight. 

Adhesions  of  the  stomach  to  adjoining  organs  are  so  common 
in  chronic  stomach  ulceration  that  gastrolysis,  or  the  detaching 
or  otherwise  treating  bands  and  short  adhesions  to  adjoining 
viscera  or  to  the  abdominal  wall,  is  performed  in  by  far  the 
greater  number  of  cases.  Such  adhesions  are  frequently  the 
only  remnants  of  ulcers  that  have  healed ;  at  other  times  they 
have  been  left  by  perforation  of  the  stomach  wall  by  an  ulcer, 
from  the  direful  consequences  of  which  they  have  saved  the 
patient.  In  many  cases  they  give  rise  to  symptoms  resembling 
ulcer,  though  the  adhesions  may  be  due  to  causes  such  as  gall- 


208  ROBSON, 

stones   outside  the  stomach  itself;  in  such   cases  the  operation 
of  gastrolysis  may  be  entirely  curative. 

I  have  performed  gastrolysis  in  56  cases,  all  of  which  have 
recovered.     The  following  case  is  given  as  an  example: 

Gastrolysis  for  adhesiofis  cmised  by  chronic  gastric  i/lcer. — Miss 
M.  B.,  aged  forty-two  years.  Twenty-two  years  ago  symptoms  of  ulcer 
of  stomach.  Since  then  has  suffered  from  vomiting  attacks  every  week 
or  two,  and  from  pain  after  food.  During  the  last  three  years  symp- 
toms more  marked.  Under  medical  treatment,  with  rest  in  bed  ;  no 
improvement.  Vomit  large  in  quantity  and  fermenting,  sometimes 
containing  blood.  Loss  of  weight  to  the  extent  of  three  stone.  Great 
tenderness  over  stomach,  especially  to  the  left.  Stomach  dilated, 
reaching  below  umbilicus  and  well  over  to  the  right. 

Operation.  On  anterior  surface  of  the  stomach  scar  of  an  old  ulcer 
is  visible.  Lesser  curvature  of  the  stomach,  closely  adherent  to  the 
liver.  Pyloric  extremity  and  first  part  of  duodenum  attached  to  gall, 
bladder  and  cystic  duct.  Adhesions  separated  and  omentum  inter- 
posed between  pylorus  and  gall-bladder. 

After-history.  Perfect  recovery.  March  7,  1900,  can  eat  any- 
thing without  discomfort,  and  is  rapidly  putting  on  flesh.  Has  gained 
20  pounds  since  her  operation.  March,  1901,  quite  well]  had  gained 
over  2  stone  in  weight. 

Many  other  examples  of  gastrolysis  could  be  given  where 
the  benefits  derived  from  operation  have  been  quite  as  great. 

Pylorodiosis,  by  which  name  is  understood  the  operation  of 
stretching  the  pyloric  sphincter,  either  by  means  of  the  fingers 
invaginating  the  stomach  wall,  when  it  is  known  as  '^  Hahn's 
operation,"  or  by  digital  or  instrumental  stretching  after  having 
made  an  opening  into  the  stomach,  when  it  is  known  as  "  Lo- 
retta's  operation,"  is  a  method  of  little  practical  value  in  the 
treatment  of  ulcer  ;  and  in  some  of  the  cases  where  I  performed 
the  operation,  though  the  immediate  results  were  good,  relapses 
subsequently  occurred.  If  performed  by  invagination  without 
opening  the  stomach  cavity,  it  is  an  operation  unattended  by 
risk.  It  may  possibly  be  of  service  in  simple  spasm  of  the 
pylorus,  but  I  have  not  much  faith  in  its  effects  being  lasting. 

Did  time  permit,  it  would    be    easy  to  give    from  my  own 


CHRONIC    ULCER    OF    THE    STOMACH.  2O9 

experience  examples  of  operations  for  all  the  complications 
of  gastric  ulcer  that  I  have  mentioued,  and,  as  many  of  the 
cases  are  of  great  individual  interest,  I  think  they  would  have 
proved  interesting  to  my  audience,  but  it  is  quite  impossible  to 
do  more  than  to  refer  to  them  unless  I  am  to  occupy  the  whole 
of  the  afternoon,  and  this  I  have  neither  the  desire  nor  the  in- 
tention of  doing. 

I  will,  however,  mention  the  results  of  my  experience  in 
operations  for  simple  diseases  of  the  stomach  out  of  over  200 
operations  that  I  have  performed. 

In  56  cases  I  have  performed  gastrolysis  for  the  separation  of 
adhesions  which  were  producing  disabling  conditions,  all  the 
patients  recovering.  In  13  cases  I  have  operated  for  hour-glass 
stomach  due  to  ulcer,  12  of  the  patients  recovering  and  being 
now  well. 

In  6  cases  I  have  operated  for  hsematemesis,  with  5  recov- 
eries ;  in  4  cases  for  fistula,  due  to  chronic  ulcer,  all  the  patients 
recovering. 

Of  the  18  cases  in  which  I  have  performed  pyloroplasty,  16 
have  recovered,  the  two  deaths  being  in  the  earlier  cases,  one 
being  due  to  perforation  in  the  second  week  after  operation. 

Of  the  posterior  gastro-enterostomies  previously  referred  to 
for  simple  diseases  of  the  stomach,  in  40  cases  there  were  two 
deaths,  both  due  to  accidental  causes,  one  being  pneumonia  in 
a  phthisical  patient. 

Of  the  anterior  gastro-enterostomies,  including  cases  operated 
on  ten  years  ago,  in  19  cases  there  were  four  deaths,  one  from 
an  accident  at  the  time  of  separation  of  a  Murphy's  button,  one 
from  shock  in  a  patient  very  exhausted  at  the  time  of  operation 
(Senn's  plates  being  used),  one  from  perforation  of  an  ulcer  on 
the  twelfth  day,  when  apparently  convalescent,  and  one  from 
peritonitis  extending  from  the  abdominal  wound. 

Of  the  2  gastroplications,  both  recovered. 

Of  the  3  cases  of  pylorodiosis,  all  recovered. 

In  8  operations  for  perforating  gastric  ulcer,  there  were  two 
deaths,  directly  following  an  operation  in  cases  treated  when 
peritonitis  was  general. 

Am  Surg  14 


2IO  ROBSON, 

Of  the  6  cases  in  which  I  directly  excised  a  gastric  ulcer, 
or  ulcers  after  opening  the  stomach  by  gastrotomy,  all  re- 
covered. 

Of  I  case  of  gastrotomy  for  the  removal  of  foreign  bodies 
and  I  for  perforating  wound  of  abdomen,  with  haematemesis, 
both  patients  recovered. 

It  will  be  seen  that  out  of  177  operations  for  simple  diseases 
of  the  stomach,  including  cases  of  perforation  and  hemorrhage, 
165  patients  recovered,  or  93.2  per  cent. 

Method  of  Employing  and  Suggested  Advantages  of  Using 
the  Developed  Bone  Bobbin. 

In  the  course  of  my  paper  reference  has  been  made  to  a 
method  I  have  been  systematically  pursuing  since  1891,  not 
only  in  stomach  operations,  but  in  nearly  all  the  operations 
which  involved  the  making  of  an  anastomatic  opening  between 
the  hollow  viscera — I  mean  the  method  of  suture  over  a  decal- 
cified bone  bobbin. 

I  have  adopted  it  in  a  very  large  number  of  cases  and  in  a 
great  variety  of  operations,  and  as  a  result  of  this  extensive 
experience  I  am  more  than  ever  convinced  that  it  is  a  reliable 
procedure  which  I  can  thoroughly  recommend  to  others.  It 
is  more  easily  demonstrated  than  described,  and  at  the  end 
of  this  discussion,  or  at  such  other  time  as  it  may  be  desir- 
able, I  shall  be  pleased  to  show  the  method  either  on  the 
cadaver  or  on  a  model.  It  is  really  very  simple,  and  only 
involves  two  continuous  sutures,  one  of  chromicized  catgut  to 
unite  the  mucous  margins  of  the  two  openings,  and  one  of  cellu- 
loid thread  to  unite  the  serous  surfaces  about  a  quarter  of  an  inch 
away  from  the  new  opening.  Pagenstecker's  thread  or  spun 
celluloid  has  replaced  silk  in  my  practice,  it  being  stronger, 
easily  sterilized  by  boiling,  and  less  absorbent. 

The  bobbin,  which  is  made  for  me  by  Messrs.  Down  Bros., 
of  London,  in  various  sizes,  from  the  small  one  required  for 
cholecystenterostomy  or  for  the  union  of  the  small  viscera  of 
children,  to  the  large  one  employed  for  gastroplasty,  or  for  the 


CHRONIC    ULCER    OF    THE    STOMACH.  211 

end-to-end  union  of  large  intestines  in  the  adult,  is  nothing 
more  than  a  cylinder  of  decalcified  bone  with  raised  ends,  which 
is  placed  in  the  new  anastomatic  opening  around  which  the 
sutures  are  applied. 

The  advantages  claimed  for  the  method  are: 

1.  That  it  secures  the  opening,  being  of  the  exact  size  in- 
tended, and  that  there  is  no  possibility  of  the  passage  being 
made  too  small  by  the  drawing  up  of  the  sutures  before  the 
knots  are  tightened. 

2.  That  it  secures  an  immediately  patent  channel  between 
the  two  anastomosed  viscera. 

3.  That  the  bobbin  protects  for  from  twenty-four  to  forty-eight 
hours  the  new  line  of  union  from  pressure  and  from  the  irrita- 
tion of  the  visceral  contents. 

4.  That  it  facilitates  the  application  of  the  sutures,  and  so 
adds  to  the  expedition  of  union  by  sutures. 

5.  That  no  foreign  material  is  left  in  the  alimentary  canal 
which  may  irritate  or  cause  subsequent  trouble,  for  the  bobbin 
rapidly  dissolves  in  the  alimentary  juices. 

6.  That  the  method  has  now  been  proved  by  ample  experi- 
ence to  be  rapid,  easy,  efficient,  and  safe. 

For  stomach  operations  it  is  used  in  gastro-enterostomy, 
in  pyloroplasty,  in  gastroplasty,  and  in  pylorectomy,  or  par- 
tial gastrectomy,  and  in  the  latter  operation  it  is  unnecessary 
to  use  more  than  two  continuous  sutures  for  the  whole  opera- 
tion. 

In  adopting  the  method,  it  is  convenient  to  begin  with  the 
serous  suture,  which  is  applied  around  the  posterior  half  of  the 
circle,  the  needle  still  threaded  is  then  laid  aside  till  the  final 
stage;  the  openings  into  the  viscera  are  then  made,  and  any 
redundant  mucous  membrane  cut  away;  the  mucous  suture  is 
now  applied,  uniting  the  posterior  half  of  the  circle  ;  the  bone 
bobbin  is  now  inserted,  and  the  mucous  suture  continued  around 
the  anterior  half-circle  until  it  reaches  the  point  where  the 
mucous  stitch  was  begun  and  where  the  loose  end  will  be  found, 
these  two  ends  are  then  tied  firmly ;  the  serous  suture  pre- 
viously laid  aside  is  now  picked  up  and  continued  around  the 


212  ROBSON, 

anterior  half-circle  until  the  loose  end  of  the  celluloid  thread 
is  reached,  when  the  two  ends  are  tied  firmly. 

The  two  hollow  viscera  are  now  united  by  a  hollow  cylinder 
of  decalcified  bone  surrounded  by  two  continuous  threads,  one 
uniting  the  mucous  margins  and  one  the  serous  surfaces  about 
one-fourth  or  one-third  of  an  inch  away  from  the  anastomatic 
opening. 


CHKONIC    ULCER    OF    THE    STOMACH.  213 


DISCUSSION. 
Dr.  William  J.  Mayo,  of  Rochester,  Minnesota. 

I  will  confine  my  remarks  to  the  question  of  gastro-enterostomy  in 
the  treatment  of  open  ulcer  of  the  stomach.  Excision  or  other  form 
of  surgical  treatment  is  indicated  in  a  few  cases  presenting  special 
features ;  but  the  common  situation  of  the  ulceration,  its  varying  ex- 
tent and  the  reasonable  possibility  that  more  than  one  ulcer  exists, 
makes  gastro-enterostomy  the  practicable  operation  in  the  majority  of 
cases.  Not  infrequently  the  site  of  the  ulcer  cannot  be  discovered, 
rendering  gastro-enterostomy  the  operation  of  necessity. 

The  symptoms  of  ulcer  of  the  stomach  depend  somewhat  upon  the 
situation  of  the  disease.  Ulcer  is  most  common  near  the  pylorus,  a 
position  which  may  introduce  certain  mechanical  features,  and  it  is 
in  the  relief  of  these  secondary  phenomena  that  this  operation  achieves 
its  triumphs.  Gastro-enterostomy  relieves  the' hyperacidity  and  allows 
prompt  emptying  of  the  ingesta,  preventing  irritation  and  aiding 
nutrition. 

The  ulcerated  stomach  is  often  contracted,  and  among  the  earlier 
writers  it  was  supposed  to  be  always  small ;  this  is  but  part  of  the 
truth.  In  acute  ulcer  it  is  small,  and  if  the  ulcerative  process  is  not 
in  the  vicinity  of  the  outlet  it  will  probably  remain  small.  On  the 
contrary,  it  is  during  the  healing  process  that  many  ulcers  in  the 
pyloric  region  become  most  troublesome.  Ulcers  in  this  situation  are 
often  extensive,  and  in  chronic  cases,  perhaps,  but  partly  cicatrized. 
Enough  distortion  or  narrowing  of  the  pyloric  outlet  takes  place  to 
materially  obstruct  the  opening,  the  unhealed  portion  of  the  ulcer 
keeping  up  irregular  symptoms  of  its  presence  in  addition  to  the  dila- 
tation. In  such  cases  symptoms  of  open  ulcer  alternate  with  periods 
of  health,  and  later  signs  of  ulcer  in  a  stomach  more  or  less  dilated 
supervene.  The  majority  of  cases  when  once  cicatrized  remain 
healed,  but  a  minority  occasionally  lapse  into  open  ulcer.  The  ca- 
pacity of  the  stomach  affected  by  ulcer  is  not  greatly  changed  in  the 
majority  of  cases,  but  if  so  it  has  a  surgical  significance.  This  gives 
us  a  good  working  basis  for  comparison.  First,  ulcers  in  the  pyloric 
region,  with  a  normal  or  enlarged  stomach,  and,  second,  ulcers  in  a 
contracted  stomach. 

As  to  the  first  group,  gastro-enterostomy  is  the  operation  of  choice. 
It  delivers  the  ingesta  at  a  point  sufficiently  remote  from  the  disease 


214  DISCUSSION. 

to  prevent  irritation,  and  the  healing  process  is  not  interfered  with,  so 
that  it  progresses  rapidly.  The  relief  to  the  mechanical  obstruction 
is  immediate  and  satisfactory.  We  have  made  gastro-enterostomy  five 
times  for  this  condition,  and  all  were  speedily  cured  and  remained 
cured.  At  times  a  small  ulcer  at  the  pylorus  causes  pyloric  spasm, 
and  symptoms  are  produced  resembling  mechanical  interference.  In 
four  operated  cases  of  pyloric  spasm  we  found  dilatation  only  once, 
and  then  not  at  all  marked.  In  this  form  of  disease  pyloroplasty  is 
fairly  effective,  but  does  not  compare  to  the  benefits  derived  from  the 
gastro-enterostomy  in  suitable  cases,  although  the  division  of  the  py- 
loric sphincter  stops  the  spasms,  and  the  enlargement  of  the  opening 
exerts  a  healing  influence  on  the  ulcer. 

Gastro-enterostomy  on  the  small  stomach  affected  by  ulcer  does  not 
give  immediate  relief  as  a  rule,  and  in  three  cases  of  our  own  the  symp- 
toms in  a  modified  degree  continued  for  some  months.  However, 
experience  goes  to  show  that  after  gastro-enterostomy  the  ulcer  will 
eventually  heal,  but  the  results  are  not  as  good  as  in  the  former  class 
of  cases.  The  pylorus  being  open  and  the  stomach  small,  it  is  self- 
evident  that  the  main  function  of  gastro-enterostomy  is  already  well 
performed,  and  it  is  probable  that  in  some  cases  the  artificial  opening 
will  not  remain  patent.  The  majority  of  dilated  stomachs  are  due  to 
old  ulcers  which  have  permanently  closed,  and  only  the  mechanical 
interference  with  the  progress  of  the  food  remains. 

As  to  gastro-enterostomy  we  have  made  sixty-one  for  all  purposes, 
using  the  Murphy  button  and  uniting  the  jejunum  to  the  anterior 
wall  of  the  stomach  as  near  the  greater  curvature  as  possible.  So  far 
as  I  am  able  to  ascertain,  this  operation  is  equally  as  good  as  the  pos- 
terior, and  easier  of  performance.  By  getting  the  opening  well  at 
the  bottom  of  the  stomach  pouch  and  near  the  greater  curvature 
there  is  little  tendency  to  regurgitant  vomiting,  gravity  aiding  the 
downward  progress.  Three-fourths  of  our  own  cases  have  been  oper- 
ated on  for  the  relief  of  non-malignant  disease,  largely  pyloric  ob- 
struction, the  result  of  healed  ulcer,  with  but  one  death  in  over  forty 
cases.     In  the  malignant  cases  the  death-rate  was  over  25  per  cent. 

Dr.  William  L.  Rodman,  of  Philadelphia. 

I  very  much  enjoyed  the  paper  of  our  distinguished  guest,  and  am 
very  certain  that  everyone  present  did  also.  His  name  has  so  long 
and  so  intimately  been  associated  with  this  work  that  his  utterances 
are  necessarily  ex  cathedra. 


CHRONIC     ULCER    OF    THE    STOMACH.  215 

I  fully  agree  in  what  he  says  about  partial  gastrectomy,  as  it  is  only 
applicable  to  a  certain  percentage  of  cases.  It  is  almost  entirely  a 
question  of  location  of  the  ulcer.  If  it  be  situated  anteriorly  and 
reasonably  free  from  adhesions,  partial  gastrectomy  has  been  shown 
to  be,  as  Mr.  Robson  states,  practicable  and  safe.  Forty  cases  that  I 
collected  from  private  correspondence  a  year  ago  gave  a  mortality  of 
15  per  cent.  If  the  ulcer  is  situated  posteriorly,  where  the  adhesions 
are  likely  to  be  intimate  and  dense,  excision  becomes  impracticable 
in  many  instances.  We  should  not  forget  that  a  very  great  majority 
of  ulcers  are  situated  posteriorly,  and,  therefore,  cannot  be  treated 
by  partial  gastrectomy.  I  also  am  in  accord  with  the  position  taken 
by  the  distinguished  essayist,  and  congratulate  him  upon  his  own  suc- 
cess in  the  treatment  of  these  cases.  I  am  glad  to  hear  him  state  that 
he  has  become  aggressive  in  the  treatment  of  hemorrhage.  While  it 
is  usually  a  mistake  to  operate  during  or  subsequent  to  the  first  hem- 
orrhage, as  soon  as  the  recurring  nature  of  the  hemorrhage  has  been 
manifested  delay  is  dangerous.  A  careful  study  of  all  published  cases 
permits  no  other  conclusion  to  be  drawn,  and  it  is  my  judgment  that 
we  will  become  even  more  aggressive  than  formerly  in  the  treatment 
of  gastric  hemorrhage. 

Dr.  Robson,  I  have  nothing  more  to  add,  except  to  say  that  I 
have  never  had  the  pleasure  of  seeing  the  elastic  ligature  employed. 
I  desire  to  thank  the  members  of  the  Association  and  the  speakers  for 
the  kind  interest  they  have  taken  in  my  paper. 


EXHIBITION  OF  METHODS  OF  MEDICAL  INSTRUC- 
TION IN  THE  JOHNS  HOPKINS  MEDICAL 
SCHOOL  AND  HOSPITAL. 


Dr.  H.  a.  Kelly  then  addressed  the  meeting  upon  the  "  Necessity 
of  Employing  the  Newer  Methods  of  Diagnosis  in  Rectal  and  Urinary 
Diseases,"  followed  by  a  practical  demonstration.  He  spoke  as 
follows : 

I  have  catheterized  the  ureters  constantly  for  the  past  thirteen  years, 
some  thousands  of  times,  and  have  so  repeatedly  demonstrated  the  ease 
with  which  this  method  of  investigation  can  be  employed,  that  it 
is  a  source  of  no  little  chagrin  to  me  to  see  the  various  complicated 
apparatuses  which  have  been  devised  and  recommended  from  time  to 
time  for  this  purpose. 

To  demonstrate  once  more  the  extreme  simplicity  and  feasibility  of 
my  procedure  to  this  society,  I  now  bring  before  you  a  patient  whom 
I  have  never  seen  or  examined  before.  As  you  observe,  I  pass  in  a 
simple  cylindrical  vesical  speculum,  the  bladder  at  once  becomes  dis- 
tended with  air,  the  ureteral  orifices  are  now  exposed  by  reflected 
light,  and  without  the  slightest  difficulty  or  hesitation  I  am  at 
once  able  to  expose  and  catheterize  the  ureter ;  as  the  catheter  enters 
the  ureter  and  is  splinted  by  the  embracing  ureteral  wall,  it  is  stripped 
off  from  the  wire  stilette  which  stiffens  it  on  the  outside  and  so  prevents 
any  coiling  up  in  the  bladder. 

The  whole  procedure,  as  you  see,  is,  I  say  again,  an  extremely  simple 
one  ;  the  difficulties  which  embarrass  the  beginner,  but  are  easily  over- 
come, are  these:  In  the  first  place,  the  bladder  does  not  always  expand 
well ;  the  fault  then  lies  in  the  posture  of  the  patient,  who  is  always  in 
the  knee-breast  position.  If  the  examiner  or  a  skilful  nurse  will  see 
that  the  patient  is  as  low  down  on  the  table  in  front  as  possible,  with 
the  side  of  the  face  touching  the  table,  while  the  thighs  are  vertical, 
this  difficulty  will  disappear. 


METHODS    OF    MRDICAL    INSTRUCTION.  21/ 

The  second  great  difficulty  is  that  examiners  search  for  the  ureteral 
orifices  by  introducing  the  end  of  the  speculum  too  far  into  the  blad- 
der. The  way  to  avoid  this  is  to  withdraw  the  speculum  until  .the 
internal  ureteral  orifice  just  begins  to  close  over  the  end,  and  then  to 
push  it  in  about  i  cm.  and  30  degrees  to  the  right  or  to  the  left ;  the 
ureteral  orifice  then  appears  as  a  little  slit  on  the  urethral  side  of  a 
slight  eminence  which  I  have  named  the  mons  ureteris. 

In  a  nulliparous  patient  it  is  always  necessary  as  a  preliminary  step 
to  let  air  into  the  vagina  in  order  to  drop  the  base  of  the  bladder  to 
the  plane  of  vision. 

This  method  of  vesical  and  ureteral  examination  is  of  extreme  value 
in  treatment  as  well  as  diagnosis.  I  probably  find  more  satisfaction 
from  its  use  in  the  diagnosis  ard  treatment  of  the  various  forms  of 
cystitis  than  in  any  other  field.  I  recall,  as  I  speak,  three  cases  of 
cystitis,  accompanied  with  extreme  suffering,  in  each  of  which  the 
patients  had  had  prolonged  treatments,  and  were  utterly  miserable 
with  their  sufferings,  and  in  a  wretched  state  of  health.  Within  five 
minutes  of  the  time  when  I  first  saw  them  and  took  them  into  the 
examining-room  my  speculum  was  introduced,  and  I  discovered  in 
each  of  the  three  a  stone  in  the  bladder,  the  simple  and  easily  remov- 
able cause  of  the  disease.  I  have  had  between  150  and  200  cases  of 
cystitis  within  the  past  five  years,  many  of  which  I  never  would  have 
been  able  to  have  handled  at  all  without  first  making  a  careful  exam- 
ination by  means  of  inspection,  and  then  following  this  up  by  regular 
topical  treatments  of  the  affected  vesical  areas  just  as  one  would  treat 
an  ulcerated  sore- throat. 

It  gives  me  great  pleasure  to  demonstrate  also  to  the  society  my 
method  of  investigating  diseases  of  the  rectum  and  sigmoid  flexure 
through  my  tubular  specula,  of  which  I  have  now  between  forty  and 
fifty  sizes  constructed  for  the  most  part  for  strictures  of  various  calibres. 
Under  such  a  method  of  examination,  easily  conducted  as  you  see, 
the  entire  rectum  balloons  out  and  is  freely  opened  to  inspection. 
Ulcerations  may  in  this  way  be  found  and  treated  topically  with 
stronger  solutions  than  we  would  dare  to  inject  in  the  bowels  with  a 
syringe.  I  also  often  pack  long  strips  of  medicated  gauze  high  up 
into  the  bowel,  filling  it  and  distending  it,  or  pledgets  of  cotton 
saturated  with  ichthyol  or  other  solutions. 

In  the  case  of  a  distinguished  colleague  who  had  suffered  exces- 
sively from  previous  examinations,  and  in  which  decided  differences 
of  opinion  had  been  expressed  as  to  whether  there  was  or  was  not  any 


2l8  METHODS    OF    MEDICAL    INSTRUCTION. 

disease  of  the  bowel  to  account  for  an  obstinate  constipation,  by 
means  of  this  tubular  inspection,  in  the  knee-chest  posture,  without 
producing  the  slightest  discomfort,  I  was  able  to  expose  to  view  an 
extensive  adenocarcinoma  high  up  in  the  rectum,  and  with  these  long 
alligator  forceps  to  remove  a  piece  of  tissue  without  his  knowledge, 
sufficient  to  show  the  nature  of  the  disease. 

I  would  like  to  emphasize  and  insist  upon  the  fact  that  if  this 
method  of  diagnosis  is  used  in  all  cases  supposed  to  be  suffering  from 
a  more  or  less  chronic  "mucous  colitis"  or  "enteritis,"  the  gratifying 
discovery  will  be  made  in  a  large  number  of  cases  that  the  disease  is 
a  purely  local  one,  limited  often  even  to  the  lower  rectum,  and  that 
sound  bowel  is  within  easy  reach  through  the  spectrum,  and  that  an 
obstinate  affection  of  years'  standing  now  becomes  amenable  to  appro- 
priate local  treatments. 


Dr.  Hugh  H.  Young  spoke  on  the  subject  of  "  Catheterization  of 
Ureters  in  the  Male." 

After  showing  the  instrument  which  he  preferred,  viz.,  the  latest 
model  of  Casper,  a  male  patient  was  brought  in  prepared  for  cys- 
toscopy by  previous  injection  of  cocaine  into  the  urethra,  and  the 
bladder  then  filled  with  salt  solution. 

The  case  proved  to  be  a  favorable  one,  and  both  ureters  were 
readily  catheterized  in  succession  and  the  instrument  withdrawn, 
leaving  the  catheters  in  the  ureters. 

Dr.  Young  then  exhibited  a  collection  of  cystoscopes,  showing  the 
history  of  ureteral  catheterization. 

The  first  instrument  was  that  devised  by  Brenner  in  1888,  but 
which  proved  unsuccessful  in  his  hands.  It  was  not  until  1893,  when 
James  Brown,  of  the  Johns  Hopkins  Hospital,  modified  Brenner's 
technique  by  employing  a  steel  stilette  for  his  catheter,  to  give  it  the 
proper  angle,  that  the  practical  value  of  Brenner's  instrument  was 
demonstrated,  and  the  male  ureters  catheterized  for  the  first  time. 
Brown  published  in  \.\\q  Johns  Hopkins  Hospital  Bulletin  five  cases  in 
which  he  had  been  successful. 

Following  this  various  instruments  have  been  brought  out  by  Nitze, 
Casper,  and  Albarran,  all  of  whom  made  subsequent  improvements 
and  modifications. 

At  present  there  exist  several  instruments  with  which  the  male 
ureters  have  been  successfully  catheterized,  but  the  difficulty  with  all 


METHODS    OF    MEDICAL    INSTRUCTION.  219 

of  these  except  Casper's  is  that  it  is  practically  impossible  to  with- 
draw the  instrument  without  pulling  out  the  catheter  from  the  ureter, 
and  that  only  one  ureter  can  be  catheterized  at  a  sitting.  In  the  in- 
strument of  Casper,  however,  this  is  not  the  case,  as  after  the  cathe- 
terization of  one  ureter,  the  catheter  can  be  immediately  thrown  out 
of  the  instrument  by  the  withdrawal  of  a  slide  which  covers  the 
channel  of  the  catheter. 

After  reinsertion  of  this  slide  the  instrument  is  ready  for  the  cathe- 
terization of  the  second  ureter,  when,  by  again  drawing  out  the  slide 
and  dislodging  the  other  catheter,  the  instrument  can  be  readily  re- 
moved without  drawing  the  catheter  out  of  the  ureters. 

As  it  generally  requires  more  than  thirty  minutes  to  collect  sufficient 
urine,  the  ability  to  withdraw  the  instrument,  leaving  the  two  catheters 
in  situ,  is  at  once  apparent. 


"Laboratory  Methods  of  Teaching  "  was  the  subject  of  remarks 
made  by  Dr.  William  H.  Welch,  who  spoke  as  follows  : 

The  value  of  laboratory  methods  of  teaching  is  now  so  generally 
recognized  that  it  may  not  be  out  of  place  to  speak  of  some  of  their 
shortcomings.  They  are  extremely  time-taking,  and  are  not  adapted 
to  present  the  entire  contents  of  any  subject.  Their  great  service  is 
in  developing  the  scientific  spirit  and  in  imparting  a  living,  abiding 
knowledge,  which  cannot  be  gained  by  merely  reading  or  being  told 
about  things.  So  important  are  these  ends,  that  it  seems  difficult  to 
overestimate  the  value  of  the  laboratory  in  scientific  teaching.  But 
there  are  aspects  of  every  subject,  even  of  such  best  fitted  for  labora- 
tory instruction,  which  it  is  important  for  the  student  to  learn,  but 
which,  either  from  lack  of  time  or  from  the  nature  of  the  subject- 
matter,  cannot  readily  be  taught  in  the  laboratory.  The  attention  of 
the  student  in  the  laboratory  is  likely  to  be  concentrated  upon  isolated 
facts,  especially  those  most  susceptible  of  easy  demonstration  to  classes, 
while  other  groups  of  facts  and  particularly  broad  general  principles 
are  in  danger  of  being  lost  to  view.  There  is,  therefore,  risk  of  loss 
of  perspective  in  relying  solely  upon  instruction  in  the  laboratory. 
Hence,  I  have  found  it  desirable  to  supplement  the  laboratory  work 
by  didactic  and  demonstrative  lectures.  Recitations  are  also  valuable 
in  systematizing  the  work  of  the  student,  in  rendering  his  knowledge 
more  precise,  and  in  affording  opportunity  to  the  teacher  to  clear  up 
difficult  or  obscure  points. 


220  METHODS    OF    MEDICAL    INSTRUCTION. 

The  methods  of  instruction  followed  in  any  particular  department 
are  left  with  us  practically,  to  the  discretion  of  the  head  of  that  de- 
partment. Some  give  no  didactic  lectures,  others  give  a  few,  and  still 
others  make  more  extensive  use  of  them.  If  a  teacher  is  convinced 
that  didactic  Icctur'es  are  useless,  it  is  not  likely  that  his  lectures  will 
be  of  much  value,  and  it  may  be  as  well  for  him  to  dispense  with  them. 

Our  first  two  years  of  instruction  are  devoted  to  the  fundamental 
medical  sciences,  and  during  this  period  most  of  the  teaching  is  in 
the  various  laboratories.  Near  the  end  of  the  second  year  the  students 
are  taught  the  methods  of  normal  physical  diagnosis,  so  that  they  are 
prepared  to  take  up  at  the  beginning  of  the  third  year  the  clinical 
study  of  disease.  During  the  last  two  years  the  dispensary  and  the 
wards  of  the  hospital  occupy  the  same  relative  position  in  the  scheme 
of  instruction  as  do  the  anatomical,  physiological,  pathological, 
and  other  laboratories  in  the  earlier  period.  We  have  found  great 
advantage  in  the  establishment  of  clinical  laboratories,  where,  during 
the  clinical  years,  the  students  are  thoroughly  trained  in  the  applica- 
tion of  microscopical  and  chemical  procedures  to  the  diagnosis  and 
clinical  study  of  disease.  These  technical  procedures  can  be  taught 
best  by  those  frequently  engaged  in  using  them,  and  at  a  time  when 
the  student  can  appreciate  their  importance;  and  it  is  a  great  relief  to 
the  courses  in  the  earlier  years,  particularly  those  in  bacteriology  and 
pathology,  to  be  freed  from  the  necessity  of  including  these  practical 
topics. 

Every  student  during  each  year  of  his  medical  course  is  obliged  to 
have  a  microscope,  and  if  he  does  not  own  one,  he  rents  one  for  a 
price  which  covers  the  interest  on  the  investment  and  repairs.  This 
microscope  is  his  property  for  the  year ;  he  uses  it  in  different  courses, 
and  he  can  take  it  to  his  home.  The  laboratories  are  open  to  the 
student  throughout  the  day,  and  he  can  spend  his  spare  time  at  his 
desk. 

Any  student  who  chooses  to  take  up  some  small  piece  of  original  or 
advanced  work  is  encouraged  to  do  so,  for  the  educational  value  of 
such  work  is  very  great.  The  number  of  those  who  have  real  capacity 
for  independent  research  and  the  creative  faculty  is,  of  course,  small, 
but  it  is  of  the  highest  importance  to  recognize  and  encourage  this 
rare  talent  when  it  exists. 

Our  pathological  laboratory  was  in  operation  before  the  establish- 
ment of  the  hospital,  and  both  were  active  before  the  opening  of  the 
medical  school.     This  resulted  in  the  establishment  of  an  unusually 


METHODS    OF    MEDICAL     INSTRUCTION.  221 

close  relationship  between  the  work  of  the  laboratory  and  that  of  the 
hospital,  which  has  been  of  great  mutual  advantage.  From  the  start 
the  pathological  service  has  been  recognized  as  an  integral  and  essen- 
tial part  of  the  hospital,  co-ordinate  with  the  clinical  services.  We 
have  pathological  internes  ranking  with  the  clinical  internes,  and  it 
cannot  be  doubted  that  this  arrangement  has  greatly  promoted  the 
scientific  work  of  the  hospital  and  given  to  it  one  of  its  most  distinc- 
tive features. 

We  have  tried  to  keep  in  view  that  it  is  the  function  of  a  great 
medical  school  not  only  to  teach,  but  also  to  advance  knowledge. 
In  the  selection  of  teachers  for  this  double  function  it  is  as  important 
to  consider  their  productive  capacity  as  their  powers  of  imparting 
knowledge,  and  I  do  not  think  it  happens  as  often  as  is  sometimes 
represented  that  a  fruitful  investigator  is  not  at  the  same  time  a  good 
teacher. 

There  is  one  inquiry  which  I  should  especially  like  to  bring  before 
this  body  of  leading  surgeons  of  this  country,  and  that  is  whether  the 
opportunities  for  training  and  advancement  in  clinical  medicine  and 
surgery  in  this  country  have  kept  pace  with  the  progress  of  medical 
science  in  the  same  measure  as  have  those  open  to  young  men  seeking 
the  higher  careers  in  anatomy,  physiology,  pathology,  and  the  other 
more  purely  scientific  branches  of  medicine?  The  laboratory  side  of 
medical  teaching  has  now,  I  believe,  in  our  leading  medical  schools 
advanced  from  the  weakest  to  the  strongest  feature  of  our  curriculum, 
and  if  after  graduation  a  young  man  chooses  for  his  career  one  of 
these  scientific  branches,  he  can  find  the  opportunity  to  secure  an  ex- 
cellent training  in  this  country,  and  after  serving  as  an  assistant  in  a 
laboratory,  and  winning  a  reputation  by  his  published  work,  he  can 
look  forward  to  securing  a  desirable  position  as  head  of  a  laboratory. 
For  such  positions  our  schools  seek  the  best  men  wherever  they  can 
find  them,  and  are  not  limited  to  the  choice  of  home  talent. 

Are  there  similar  opportunities  for  prolonged,  thorough  training  in 
clinical  medicine  and  surgery  after  graduation  and  for  promotion  ? 
We  afford  such  an  opportunity  here  to  a  few  men  who  are  fortunate 
enough  to  secure  the  more  permanent  resident  positions  over  the 
regular  internes,  but  in  general  the  hospitals  of  this  country  are  so 
organized  as  not  to  offer  like  opportunities  to  those  seeking  the  higher 
careers  in  medicine  and  surgery.  In  consequence  of  what  I  believe 
to  be  a  defective  organization  of  our  hospitals,  the  young  clinician 
with  high  aims  does  not  find  opportunities  for  acquiring  experience 


222  METHODS    OF    MEDICAL    INSTRUCTION. 

and  making  a  reputation  analogous  to  those  available  to  anatomists, 
physiologists,  and  pathologists.  Did  time  permit,  it  would  not  be 
difficult  to  show  that  the  work  of  the  hospital  also  suffers  thereby. 

Furthermore,  what  chance  is  there  that  a  man  who  has  made  a  high 
reputation  in  clinical  medicine  or  surgery  in  one  place  will  be  called 
to  a  desirable  position  elsewhere?  In  consequence  of  the  relation 
usually  existing  between  our  hospitals  and  medical  schools,  and  for 
other  leasons,  our  schools  restrict  themselves  to  the  selection  of  local 
physicians  and  surgeons  for  their  important  clinical  chairs  to  a  much 
greater  extent  than  in  the  choice  of  anatomists,  physiologists,  and 
pathologists.  Hence  it  is  that  clinical  medicine  and  surgery  in  their 
higher  fields  do  not  offer  to  young  men  the  opportunities  and  attrac- 
tions in  this  country  which  they  should  do,  and  which  they  do  in 
Germany  and  some  other  foreign  countries. 

In  conclusion,  I  beg  to  say  that  our  laboratories  are  open  for  your 
inspection,  and  we  shall  be  glad  to  see  any  of  you  there.  We  have 
had  no  money  to  put  on  external  adornment,  but  we  have  a  very  fair 
equipment  for  actual  work  and  good  facilities  for  instruction. 


PHLEBITIS  FOLLOWING  ABDOMINAL  OPERATIONS. 


By  albert  VANDER  VEER,  M.D., 

ALBANY,   N.  Y. 


The  great  field  of  abdominal  surgery  has  been  so  carefully 
and  thoroughly  investigated,  the  operative  technique  perfected 
to  such  an  extent,  the  many  favorable  recoveries,  and  fatal 
cases  looked  into  with  such  earnestness,  that  we  go  on  doing 
operations  with  perhaps  as  little  strain  and  anxiety  as  used  to 
present  to  the  operating  surgeon  in  much  less  serious  surgical 
work,  yet  occasionally  some  unlooked  for  complication  will 
arise.  When  this  occurs  our  anxieties  begin,  and  we  are  led 
to  wonder  as  to  the  etiology  that  is  bringing  our  patient  more 
prominently  in  sight  as  a  subject  for  further  study  and  investi- 
gation. 

There  are  times  when,  as  regards  my  own  experience,  I 
approach  my  cases  with  greater  fear  as  to  favorable  results  than 
at  other  periods.  There  are  occasions  when  I  look  for  a  more 
serious  type  of  lesions  in  the  same  relative  class  of  cases.  My 
abdominal  work  during  an  epidemic  of  grippe  has  often  given 
me  much  greater  care  and  anxiety  than  when  these  atmospheric 
conditions  did  not  prevail.  I  am  sure  that  in  my  work  in 
appendicitis  I  have  been  led  to  look  upon  the  months  of  August 
and  September  as  bringing  to  me  a  greater  number  of  cases,  and, 
more  particularly,  of  the  acute,  fulminating  or  perforating  form, 
because  of  the  diet  that  young  people  indulge  in  at  that  time. 
Also  during  the  months  of  December  and  January,  when  more 
active  exercise  is  being  indulged  in — skating,  tobogganing 
or  coasting — the  out-door  exposure  being  greater  for  young 
people  at  this  period;  but  not  until  recently,  and  in  a  compara- 
tively short  time,  have  I    had  that   rather  startling  symptom, 


224  VANDER    VEER, 

that  to  the  obstetrician  is  alarming,  and  to  the  operating  surgeon 
not  at  all  comforting,  i.  e.,  phlebitis.  Within  the  past  two  years  I 
have  had  four  cases,  and  of  such  a  nature  that  I  feel  them  worthy 
of  report.  We  really  meet  with  so  few  post-operative  complica- 
tions in  our  abdominal  work  at  the  present  time,  and  are  so 
hopeful  of  quick  return  to  health,  that  we  are,  perhaps,  at  times 
rather  buoyant  in  our  encouragement  to  patients  and  their 
friends  as  to  immediate  recovery. 

When  doing  serious  abdominal  operations,  particularly  when 
working  deep  down  in  the  pelvis,  and  when  ligating  the  uterine 
and  ovarian  vessels,  and,  as  is  sometimes  the  case,  perhaps  when 
there  are  many  adhesions  present,  a  mass  ligature  is  applied, 
I  have  often  wondered  that  we  did  not  get  thrombosis  and  more 
dangerous  complications  of  the  venous  circulation  than  one 
meets  with  or  hears  of  as  the  experience  with  other  operators. 

I  can  call  to  mind  but  one  fatal  case  of  pulmonary  thrombosis 
following  this  class  of  operations,  and  when  my  attention  was 
called  to  the  first  of  the  cases,  to  which  I  am  about  to  refer,  I 
was  alarmed  and  disturbed,  fearing  our  technique  had  failed  us 
in  some  way,  the  fault  being  either  in  the  neglect  of  proper 
attention  to  the  alimentary  tract  before  the  operation,  or  that, 
perhaps,  the  ligature  had  been  improperly  applied,  or  possibly 
infected  in  itself.  One  may  reason  clearly  and  impartially  as 
to  a  complication  of  this  kind,  but  notwithstanding  your  firm 
belief  in  your  preparation  of  patients  by  a  nurse  in  whom  you 
have  all  confidence,  or  in  your  operating-room  nurse,  who  has 
conducted  skilfully  and  intelligently  the  preparation  of  ligatures, 
sterilization  of  instruments  and  water,  gauze,  sponges,  etc.,  yet 
a  disagreeable  suspicion  enters  your  mind  of  sepsis.  You  feel 
at  once  like  charging  somewhere  along  the  line  the  entrance  of 
this  element  in  disturbing  the  usual  recovery  of  the  patient, 
who  has  been  promised  much,  but  delayed,  at  least,  to  weeks  of 
additional  treatment.  In  your  mind  is  the  constant  fear  of  some 
sudden  death,  such  as  one  who  has  had  any  great  obstetrical 
practice  in  earlier  life  calls  to  mind  as  the  result  of  thrombosis 
from  the  puerperal  infected  uterus. 

I  say  these  are  the  thoughts  that  come  to  one,  and  yet  when 


PHLEBITIS     FOLLOWING    ABDOMINAL    OPERATIONS.       225 

we  consider  the  great  range  of  pathological  lesions  met  with  in 
the  pelvis,  and  that  are  now  treated  so  intelligently  and  success- 
fully, I  do  not  know  that  we  ought  to  be  much  surprised  in  hav- 
ing these  complications  of  venous  thrombosis  ;  however,  in  my 
own  experience,  as  I  have  stated,  and  in  my  reading  and  recol- 
lection of  personal  conversation  with  professional  friends,  these 
cases  are  certainly  rare.  It  is  not  pleasant  to  promise  a  patient 
that  they  are  to  be  well  of  their  operation  within  a  stated  period, 
and  then  have  that  time  doubled,  or  increased  threefold,  as  I 
am  sure  has  been  my  experience  in  these  cases  of  phlebitis,  and 
where  we  feel  it  is  absolutely  necessary  to  keep  the  patient  quiet 
long  enough,  so  that  there  may  be  no  blood-clot  carried  into  the 
circulation  to  be  followed  by  a  sudden  and  unexpected  death. 

The  following  cases  are  reported  because  I  believe  them  to 
be  rare.  I  have  nothing  to  add  to  what  has  already  been  hinted 
at  as  regards  the  pathology.  In  the  summing  up  of  the  treat- 
ment possibly  nothing  new,  rather  a  judicial  presentation  of 
what  is  rational,  calm,  and  well  understood. 

It  will  be  noted  that  these  cases  come  somewhat  near  each 
other,  and  immediately  after  moving  into  a  splendid  new  hospital 
plant,  and  beginning  our  work.  Our  other  operations  of  every 
kind  were  doing  well,  and  every  usual  precaution  had  been 
exercised. 

Case  I. — Mr.  H.  N.  S.,  aged  fifty-eight  years,  for  nearly  a  year  had 
suffered  from  gradual  enlargement  of  the  liver,  and  who  permitted  an 
exploration  on  April  12,  1900.  The  growth  was  found  to  be  an  angi- 
oma in  connection  with  the  lobus  spigelii.  This  was  removed  by 
Dr.  Macdonald  and  myself.  The  tumor  rather  larger  than  my  first. 
Wound  closed  by  layer  sutures.  Patient  progressed  very  favorably 
until  April  26th,  when  he  developed  marked  symptoms  of  phlebitis  in 
the  left  leg.  No  especial  tenderness  in  the  pelvis,  nor  about  the  ab- 
dominal cavity.  The  swelling  continued  for  a  long  time,  although 
this  patient  was  under  a  similar  line  of  treatment  afterward  pursued 
in  the  other  cases.  Ultimately  the  oedema  and  swelling  disappeared, 
but  the  patient  was  over  three  months  in  regaining  the  entire  use  of 
his  leg.  Although  the  disease  of  the  liver  has  returned  in  this  case, 
the  patient  at  the  present  time  shows  no  redema  or  any  complication 
of  the  venous  circulation. 

Am  Surg  15 


226  VANDER    VEER, 

Case  II. — Mrs.  A.  F.  C,  aged  forty  years,  referred  to  me  by  Dr.  J. 
M,  Bigelow,  with  a  history  of  a  gradually  increasing  enlargement  of 
the  abdomen.  Patient  gave  a  very  good  family  history,  but  had  lost  in 
flesh  during  the  past  year,  and  now  presented  the  marked  look  of  suf- 
fering that  accompanies  ovarian  disease.  Patient  married  several 
years ;  never  pregnant ;  menstruation  somewhat  irregular,  and  some- 
what profuse  at  times ;  urine  normal ;  condition  of  bowels  not  well 
defined.  On  examination  she  presented  the  appearance  of  a  multi- 
locular  ovarian  cyst. 

Operation  May  20,  1900.  It  was  found  to  be  a  case  of  double  ova- 
rian tumor,  one  from  each  side,  but  with  scarcely  any  adhesions  and 
no  great  embarrassment  during  the  operation.  Each  pedicle  secured 
by  silk  ligature,  and  the  peritoneal  surface  stitched  over  with  very  fine 
silk. 

Bowels  were  thoroughly  emptied  previous  to  the  operation  ;  a  good 
movement  secured  at  the  end  of  the  second  day,  and  the  patient  went 
on  progressing  as  favorably  as  one  could  wish,  giving  no  anxiety  to 
nurse  or  myself.  About  the  twelfth  day  she  complained  of  pain  in  the 
left  leg,  which  I  was  inclined  to  attribute  to  the  position  she  had  been 
in — resting  on  that  side,  and  thought  at  first  it  might  be  a  rheumatic 
condition.  I  am  frank  to  confess  that  I  did  not  grasp  quickly  the  pos- 
sibility of  circulatory  complications ;  but  at  the  end  of  forty-eight 
hours  the  pain  had  increased  to  such  an  extent  that  the  inability  to 
move  the  limb,  the  rise  of  temperature,  with  slight  increase  of  pulse 
rate,  led  me  to  make  a  more  careful  examination,  and,  not  finding  any 
complication  within  the  pelvis  by  bimanual  search,  I  was  forced  to 
recognize  a  condition  of  phlebitis  implicating  the  femoral  vein,  the 
external  saphenous,  and  the  veins  of  the  calf  of  the  leg,  the  latter 
being  very  sensitive  to  the  touch.  Patient's  bowels  were  promptly 
emptied  by  the  use  of  calomel  and  salines,  sufficient  codeine  given  to 
afford  relief  from  the  pain,  carbonate  of  ammonia  administered, 
together  with  diuretics,  as  the  secretion  of  urine  was  not  very  free, 
and  the  limb  wrapped  in  cotton  and  oil  silk,  absolute  rest  being  en- 
forced. While  her  convalescence  was  delayed  fully  three  weeks,  yet 
this  patient  made  a  good  recovery,  with  no  permanent  disability,  the 
anxiety  of  her  case,  however,  being  as  great  as  any  I  have  had.  The 
husband  being  an  intelligent  man,  and  knowing  the  danger  of  throm- 
bosis in  connection  with  phlebitis,  gave  us  no  little  amount  of  trou- 
ble in  his  inquiries  and  expression  of  fears  as  to  sudden  death.  At 
the  present  time  this  patient  presents  a  picture  of  absolute  health, 


PHLEBITIS    FOLLOWING     ABDOMINAL    OPERATIONS.       22/ 

scarcely  to  be  recognized  as  the  case  upon  whom  we  operated  a  year 
ago. 

Case  III. — Mrs.  J.  N.,  aged  forty-four  years;  married;  family  his- 
tory negative.  Patient  has  always  complained  of  pain  in  her  abdo- 
men and  more  or  less  vaginal  discharge.  Had  diphtheria  at  nine- 
teen, and  has  suffered  much  from  sore  throat  at  various  times  since. 

In  1S93  had  typhoid  pneumonia.  For  the  past  three  years  has  been 
in  bed  much  of  the  time.  Has  always  worked  as  much  as  her  strength 
would  permit.  No  unusual  exposure.  Bowels  always  constipated,  and 
has  had  much  bladder  trouble  for  three  or  four  years ;  sometimes  could 
not  retain  urine,  at  other  times  had  to  be  catheterized.  Two  years  ago 
had  a  severe  bronchial  cough  which  lasted  for  some  time,  and  has  had 
more  or  less  rheumatic  trouble  since.  After  her  attack  of  diphtheria 
she  noticed  a  bearing-down  pain;  menstruation  irregular ;  at  times  a 
leucorrhcea  was  noticed,  and  patient  has  grown  gradually  worse.  Pain 
felt  in  hips,  back,  and  chest.  Has  had  a  number  of  chills  at  irregular 
intervals.  For  past  two  years  has  not  been  able  to  do  much  work,  and 
in  bed  the  greater  part  of  the  time.  Appetite  fair  ;  no  nausea  nor  vom- 
iting; bladder  trouble  at  the  present  time  (June,  1900),  very  much 
better.  Has  lost  in  weight  nearly  fifty  pounds,  and  -is  much  weaker 
than  she  was  a  year  ago;  greatly  constipated.  Has  noticed  some 
enlargement  of  abdomen,  and  on  being  examined  by  her  family  phy- 
sician, Dr.  A.  J.  Blessing,  was  told  she  had  some  tumor  in  connection 
with  the  uterus,  probably  fibroid  in  character. 

I  saw  her  on  June  13,  1900,  confirmed  the  diagnosis  made  by  her 
family  physician,  and  advised  an  operation,  because  of  the  fixed  posi- 
tion of  the  fibroid  in  the  pelvis,  which  I  believed  was  also  causing 
some  pressure  upon  the  vessels,  and  producing  much  of  her  trouble. 
Examination  of  urine  normal.  Abdomen  presented  a  rounded,  sym- 
metrical appearance;  slight  tenderness  in  lower  portion  ;>  reflexes 
normal. 

On  June  15,  1900,  I  did  a  median  incision,  and  exposed  the  fibroid, 
which  filled  the  pelvis  snugly.  By  means  of  the  corkscrew  it  was 
brought  well  up  into  the  incision  ;  intestines  kept  back  by  means  of 
large  gauze  sponges ;  broad  ligaments  clamped ;  fibroid  removed  ; 
amputation  done  just  above  the  internal  os.  After  controlling  the 
ovarian  and  uterine  arteries,  the  peritoneal  surface  of  the  broad  liga- 
ment was  brought  together,  and  the  stump  closed  with  silk  sutures,  the 
peritoneum  over  that.  Incision  in  the  abdomen  closed  by  through- 
and-through  silkworm-gut  sutures,  and  silver-foil  dressing. 


228  VANDER     VEER, 

This  patient  presented  no  unusual  complication  in  her  recovery 
until  the  evening  of  June  30th,  when  her  temperature  reached  101.5°, 
and  she  complained  of  much  pain  in  her  left  leg.  On  examination  it 
was  noticed  that  she  had  phlebitis  of  the  femoral  vein  and  of  the  in- 
ternal saphenous  and  of  the  veins  of  the  calf  of  the  leg,  the  left  leg 
being  much  swollen.  The  case  presented  as  one  of  distinct  phlebitis 
on  that  side.  There  was  no  marked  tenderness  on  examination  of  the 
pelvis.  Bimanual  examination  did  not  reveal  any  phlegmon,  and, 
while  there  had  been  much  obstinate  constipation,  the  patient  had 
succeeded  in  getting  a  movement  by  the  use  of  the  triplex  pills  and 
enemas.  The  leg  was  dressed  with  cotton  and  oil  silk,  and  elevated ; 
anodynes  used  to  control  pain  ;  cathartics  were  needed  to  keep  her 
bowels  open.  Patient  was  restless  and  despondent  much  of  the  time, 
but  eventually  made  a  good  recovery,  and  was  discharged  from  the 
hospital  July  28th,  able  to  walk  about  with  the  aid  of  crutches.  She 
returned  to  her  home,  and  while  suffering  more  or  less  neuralgic  pain, 
yet  I  am  told  by  her  family  physician  she  has  made  a  very  satisfactory 
recovery.  This  was  a  marked  case,  and  her  convalescence  was  greatly 
delayed  by  reason  of  the  attack. 

Case  IV. — Mr.  W.  H.  B.,  aged  twenty-nine  years;  married  ;  habits 
good  ;  family  history  negative ;  had  diseases  of  childhood,  but  always 
considered  himself  well  with  the  exception  of  some  decided  constipation 
at  times;  fairly  hard  worker;  had  seen  severe  exposure  ;  uses  tobacco 
moderately ;  no  alcohol,  nor  any  history  of  specific  trouble.  Con- 
sidered himself  well  until  December,  1899;  then  one  day  noticed  a 
severe  pain  in  the  right  iliac  fossa,  which  gradually  grew  worse  until 
the  fifth  day,  when  he  was  ordered  to  bed  by  his  physician.  No  vom- 
iting. Patient  remained  in  bed  about  a  week,  and  then  felt  very  well. 
Had  another  attack  two  months  later,  and  since  then  has  had  several 
attacks;  not  necessary  for  him  to  be  confined  to  his  bed  until  this  last 
attack,  about  a  month  ago;  was  then  in  bed  for  two  weeks,  and  suf- 
fered severe  pain,  which  was  more  localized,  however;  no  nausea  or 
vomiting  presented  ;  bowels  regular ;  had  no  chills  or  fever ;  bladder 
normal  in  its  functions,  and  no  cough  :  urine  normal. 

Physical  Examination.  Patient  presented  a  strong,  muscular  ap- 
pearance ;  pulse  strong,  full  and  regular ;  abdomen  symmetrical  and 
flattened,  if  anything ;  respiration  normal ;  slight  tenderness  over  the 
region  of  appendix.  Diagnosis  of  his  physician  (Dr.  Ball)  confirmed — 
i.e.,  recurrent  catarrhal  appendicitis. 

Operation,  June  21,  1900.     The   appendix  was   found   very  long. 


i 


PHLEBITIS    FOLLOWING    ABDOMINAL    OPERATIONS.       229 

measuring  nearly  seven  inches  and  containing  several  concretions  of 
fecal  matter  in  distal  extremity ;  some  few  adhesions,  but  not  severe. 
The  stump  was  invaginated  with  fine  silk — in  fact,  usual  operation 
done,  and  usual  method  of  closing  incision  by  layer  sutures;  no  drain- 
age. This  patient  progressed  very  favorably,  and  had  no  untoward 
symptoms.  Slight  rise  of  temperature  on  third  day.  On  the  26th  the 
evening  temperature  was  102°,  and  patient  complained  of  decided  pain 
in  the  left  leg.  Marked  pain  on  pressure  over  the  femoral  vessels  and 
the  calf  of  the  leg.  On  the  28th  the  temperature  reached  103!°,  ^^' 
went  down  the  morning  of  the  29th  to  gg^° ;  then  up  to  103°,  and  re- 
mained there  until  the  morning  of  July  ist,  when  it  dropped  to  99^°. 
The  patient's  limb  was  wrapped  in  cotton  and  oil  silk,  carbonate 
of  ammonia  given  internally,  bowels  thoroughly  emptied,  and  from 
this  time  on  there  was  no  rise  of  temperature,  nor  did  his  pulse 
go  above  98.  He  made  a  good  recovery,  and  left  the  hospital  July 
10,  1900.  The  swelling  gradually  disappeared,  and  when  I  saw  him 
a  month  later  there  was  no  tenderness  nor  thickening  of  the  vessels  to 
be  made  out.  This  patient  had  no  unpleasant  symptoms  on  pressure 
over  the  region  of  the  appendix  after  the  operation,  nor  did  he  give 
evidence  of  pelvic  com.plications. 

The  literature  on  the  subject  of  venous  thrombosis  and  of 
phlebitis  following  abdominal  operations  is  not  very  extensive. 
The  contributions  of  such  men  as  Lennander,  of  Upsala ; 
Strauch,  of  Moscow ;  VVyder,  Mahler,  Lee,  McKenzie,  Fox, 
and  more  recently  of  Welch,  Coe,  and  Willy  Meyer,  give  about 
all  that  is  to  be  obtained  bearing  upon  the  subject,  and  yet  it  is 
not  absolutely  clear  to  either  of  these  authors  that  the  cause  is 
of  septic  origin. 

Welch  is  particularly  impressive  in  this  direction,  and  we  cer- 
tainly have  much  more  to  gather  in  and  study  carefully  before 
we  can  be  quite  sure  as  to  the  causes  of  this  lesion.  In  none  of 
my  cases  could  be  found  a  condition  of  auto-infection,  for  I  am 
particularly  thorough  in  having  the  bowels  emptied  before  an 
operation  and  to  attend  to  it  somewhat  promptly  afterward. 
In  looking  over  the  histories  of  these  cases  there  does  not  pre- 
sent any  evidence  of  complications  in  this  direction.  I  am  not 
altogether  clear  but  that  the  tight  bandage  may  have  had  some- 
thing to  do  with  two  of  my  cases.     The  bandage  I  now  employ 


230  VANDER    VEER, 

is  the  Scultetus,  and  it  is  sometimes  possible  to  bring  the  lower 
band  a  little  tighter  than  others,  something  I  am  now  convinced 
my  nurses  should  be  warned  against.  In  neither  of  these  cases 
was  there  delay  in  union  of  the  wounds.  All  went  well,  and 
healing  was  primary  and  thoroughly  aseptic.  There  was  no  pro- 
longed vomiting  from  anaesthesia,  and  in  neither  case  was  there 
the  evidence  of  phlegmon,  either  in  the  pelvis  or  otherwise. 

It  will  be  noted  that  pain  was  one  of  the  pronounced  symp- 
toms, and  in  two  cases  out  of  proportion  to  the  apparent  lesion, 
butthe  vessels  did  present  the  characteristic  cord-like  sensation, 
and  within  a  very  short  time  after  the  pain  indicated  the  lesion 
that  was  present. 

The  feel  and  sensation  of  distress  and  increased  pain  was  an 
early  symptom.  It  will  be  noted  that  the  temperature  and  pulse 
were  markedly  accelerated  when  the  ushering  in  of  the  lesion 
presented. 

These  cases  indicate  that  neither  sex  escapes,  nor  can  it  be 
said  that  the  operations  were  all  of  the  same  nature.  One  was 
an  operation  for  appendicitis ;  another  a  case  of  uterine  fibroid 
of  long  standing.  In  this  latter  case  it  is  to  be  noted  that  the 
patient  had  suffered  from  phlebitis  in  early  life,  and  had  pre- 
sented all  of  the  objective  symptoms  of  varicose  veins. 

One  was  a  case  of  double  ovarian  tumor,  another  a  rare  form 
of  tumor  of  the  liver,  so  that  the  four  cases  present  quite  a 
variety  of  lesions.  The  position  of  the  patient  during  the  time 
of  the  operation  I  have  studied  carefully,  and  am  able  to  say 
there  was  no  change  from  the  horizontal  position,  with  no 
pressure  upon  any  particular  part  of  the  lower  extremities  ;  no 
elevation  of  the  pelvis  or  changed  position  especially.  Loss  of 
blood  but  slight  in  either  case.  Condition  of  patient,  so  far  as 
being  an?emic  or  feeble  or  weak,  was  indicated  to  the  contrary, 
with  the  exception  of  the  case  suffering  from  tumor  of  the  liver, 
where  there  was  a  marked  anaemia  present,  and  he  did  not  take 
ether  especiall}''  well.  At  one  time  he  was  quite  cyanosed,  and 
required  artificial  respiration  for  a  short  period. 

The  kind  of  ligature  used  was  the  same  I  have  employed  in  all 
of  my  abdominal  operations,  the  finest  silk  sufficiently  strong  for 


i 


PHLEBITIS    FOLLOWING    ABDOMINAL    OPERATIONS.       23I 

the  purpose  ;  no  catgut  used  within  the  peritoneal  cavity.  While 
I  have  all  confidence  in  the  latter,  still  my  early  experience  as  a 
general  surgeon  has  made  silk  a  favorite  ligature,  and  with  the 
sterilization  we  are  able  to  give  it  I  have  no  reason  to  make  a 
change  in  this  direction. 

It  has  occurred  to  me  that  the  anatomical  distribution  of  the 
veins  on  the  left  side,  as  in  varicocele,  may  have  a  bearing  upon 
the  pathology  of  these  cases.  Constipation  certainly  must  be 
considered,  and,  as  in  all  work  within  the  abdomen,  should  be 
overcome  or  relieved  before  operating. 

That  the  cases  have  made  a  good  recovery  is  a  source  of  com- 
fort and  consolation,  but  that  they  give  additional  care  during 
convalescence  cannot  be  denied,  and  one  feels  that  if  we  can  reach 
the  etiology  and  pathology  of  such  a  condition  it  would  be  very 
desirable,  eliminating  even  this  factor  of  worry  in  this  class  of 
surgery. 

Ether  was  used  as  the  anaesthetic  in  all  these  cases  ;  urine  care- 
fully examined  and  found  to  be  normal. 

Concerning  venous  thrombosis  of  the  lower  extremities  after 
coeliotomy  in  the  high  pelvis  position,  and  ether  narcosis,  Dr. 
Strauch  remarks  :  "  After  attending  the  Fifth  Gynecological 
Congress  in  Breslau,  in  May,  1893,  after  visiting  Vienna  and 
attending  the  Schautaschen  clinic,  and  seeing  ether  narcosis  for 
the  first  time,  and  having  had  some  unpleasant  experience  in 
asphyxiation  from  chloroform,  I  determined  to  try  ether  in  my 
private  clinic."  On  June  i,  1893,  he  performed  his  first  cosli- 
otomy  under  ether  narcosis,  in  the  high  pelvis  position,  and  up 
to  January,  1894,  had  done  nineteen  cceliotomies  :  Seven  ovari- 
otomies ;  five  myomectomies  ;  three  appendage  operations  ;  two 
ventral  fixations  ;  two  extra-uterine  pregnancies.  And  of  these 
cases  he  observes  that  three  suffered  from  venous  thrombosis  of 
the  left  lower  extremity.  He  describes  these  cases  somewhat 
fully  as  follows  : 

Case  I. — Ansemic  patient,  aged  forty-six  years ;  strong  heart-beat. 
Had  been  curetted  three  times  on  account  of  hemorrhage  from  a 
myoma;  success  only  moderate.  On  June  i,  1893,  supravaginal 
amputation  of  uterus  on  accouat  of  a  fast-growing    myoma  in    the 


232  VANDER    VEER, 

anterior  uterine  wall.  Bleeding  from  appendages  severe.  Intraperi- 
toneal treatment  of  stump.  Operation  one  and  one-half  hours.  Ether, 
360  grammes.  Normal  convalescence  to  seventh  day.  June  9th,  pain 
in  left  parametrium  ;  left  lower  extremity  much  swollen  ;  subcutaneous 
veins  visible.  Combined  examination  revealed  pelvis  in  safe  condi- 
tion. Under  high  elevation,  cotton  and  oil-silk  bandages,  oedema  and 
hardness  of  veins  disappeared  in  three  weeks.  Leg  bandaged  when 
patient  left  bed  on  thirty-first  day,  and  continued  swollen. 

Case  II. — June  10,  1S93,  i^emoved  an  ovarian  cyst,  size  of  a  man's 
head.  Patient,  aged  twenty-eight  years,  powerfully  built,  neurasthenic 
woman.  Cyst  circumscribed  ;  adhesions  on  right  side  ;  cyst  twisted  on 
its  pedicle  360°.  Tied  in  three  places;  silk  sutures;  operation  lasted 
twelve  minutes.  Uneventful  recovery  ;  stitches  removed  on  tenth  day, 
and  primary  union. 

On  fourteenth  day  there  arose  a  typical  venous  thrombosis  of  left 
lower  leg.  Patient  remained  two  weeks  longer  in  bed,  and  the  last 
time  seen  she  complained  of  pain  and  slight  swelling  of  the  leg. 

Case  III. — Ovariotomy,  January  20,  1894.  Patient,  powerfully-built 
woman,  aged  thirty-two  years  ;  the  end  of  third  month  of  her  first  preg- 
nancy. There  was  a  non-adherent,  immense  tumor  springing  from  the 
left  ovary,  and  coming  from  a  small,  irregular  cyst,  with  very  strong 
adhesions.  Tumor  had  developed  so  rapidly  before  patient  was  seen 
that  the  incision,  of  necessity,  was  lengthened  over  the  navel.  The 
stump  was  eleven  millimetres  wide,  with  a  twisted  pedicle,  the  latter  tied 
off  in  three  parts,  and  sutured  with  silk,  as  far  as  possible,  toward  the 
tumor. 

After  removal  of  the  tumor  the  patient  was  put  back  in  the  horizon- 
tal position.  Was  five,  possibly  eight  minutes  in  high  pelvis  position, 
but  legs  were  held  by  a  very  intelligent  midwife,  and  knees  bent  high- 
est on  right  side.  Ether  used,  240  grammes.  There  were  uterine  con- 
tractions on  the  day  after  the  operation,  and  patient  was  given  tincture 
of  thebane.  On  the  third  day  there  was  slight  osdema  about  left  mal- 
leolus, which  quickly  disappeared.  One  hundred  hours  after  opera- 
tion the  patient  awakened  with  a  loud  cry ;  shortness  of  breath,  cold 
perspiration  ;  small,  ragged  pulse,  and  strained,  anxious  countenance. 
No  doubt  was  left  regarding  the  diagnosis — embolus  of  the  lung  had 
occurred.  Under  treatment  the  patient  recovered  again  on  the  third 
day  ;  but  lower  extremity,  on  the  fourteenth  day  after  the  operation, 
still  looked  somewhat  as  in  the  beginning.     One  could  see  the  sub- 


PHLEBITIS     FOLLOWING    ABDOMINAL    OPERATIONS.       233 

saphenous  veins  show  through.     Abdominal  wound  healed  kindly,  and 
pregnancy  continued  to  term. 

Dr.  Strauch  asks  :  "  How,  then,  is  this  highly  fatal  complica- 
tion to  be  explained  ?"  From  personal  observation  with  the 
high  pelvis  position,  and  from  several  operators  in  Austria  and 
Germany,  I  am  convinced  that  no  fault  is  to  be  attributed  to 
my  table.  The  Rosshair  table  protects  the  knees  nicely  from 
pressure,  but  this  position  does  give  a  somewhat  hindered  cir- 
culation of  the  lower  limbs.  Chloroform  brought  no  disaster 
from  this  position.  Under  chloroform  I  was  always  accustomed 
to  guide  my  prognosis  by  the  appearance  of  the  pulse  curve 
the  first  three  days  after  the  operation,  but  it  is  not  possible 
under  ether.  Under  the  nineteen  cceliotomies  twelve  cases  are 
recorded  where  the  pulse  the  first  three  days  went  up  to  120. 
In  none  of  these  cases  was  there  great  loss  of  blood.  It  ap- 
pears, therefore,  the  specific  working  of  the  ether,  plus  the  high 
pelvis  position,  has  brought  about  this  unpleasant  complication. 

It  is  somewhat  remarkable  that  this  always  happens  in  the 
left  lower  extremity,  and  one  cannot  help  but  be  impressed 
with  the  idea  that  the  left  leg  is  more  strongly  bent  during  the 
operation,  because  held  in  the  right  hand  of  the  assistant.  I  am 
not  at  all  certain  whether  to  blame  the  ether  or  the  position, 
but,  in  order  to  obviate  the  leg  resting  upon  the  sharp  edge  of 
the  table,  I  do  not  allow  it  to  be  held  by  an  assistant,  but 
fastened  up  with  straps. 

It  will  be  observed  that  this  report  was  made  in  1894,  and 
yet  how  few  cases  or  papers  on  the  subject  have  been  presented 
to  the  profession  since. 

Treatment  certainly  consists  in  rest,  elevation  of  the  limb, 
free  movement  of  the  bowels,  anodynes  to  control  pain,  later 
hypnotics  to  afford  sleep,  and  diffusible  stimulants  and  tonics 
as  may  be  required. 

Bibliography. 

Lennander.     Centralblatt  (iir  Chirurgie,  May  13,  1899. 
Coe.     Medical  News,  July  i,  1899. 
Strauch.     Centralblatt  iiir  Gynakologie,  1894,  p.  304. 
^  Meyer.     Annals  of  Surgery,  May,  1901. 
Welch.     AUbutt's  System  of  Medicine,  Thrombosis  and  Embolism,  p.  195. 


234  DISCUSSION, 


DISCUSSION. 

Dr.  George  Fowler,  of  New  York. 

The  importance  of  this  lesion  complicating  abdominal  operations 
deals  of  course  with  the  frequency  of  its  occurrence,  with  its  mortal- 
ity, and  with  the  disability  following  its  occurrence.  In  reviewing 
the  work  during  the  past  fifteen  years  in  abdominal  operations,  I  find 
that  there  were  upward  of  3000  cases  in  the  hospitals  with  which  I  am 
connected,  and  that,  deducting  those  cases  in  which  opportunity  was 
not  afforded  for  the  development  of  phlebitis  (for  it  is  a  development 
of  some  days,  and  frequently  weeks,  following  operation),  there  were 
271 1  cases.  Of  these  16  developed  phlebitis,  or  0.59  per  cent.  Of 
these  two  were  double,  or  two-sided,  to  followed  cases  of  appendicitis 
in  which  decided  infection  was  present.  The  remaining  6  occurred  in 
operations  upon  the  pelvic  organs  not  necessarily  involving  a  pre- 
existing or  followed  by  a  post-operative  septic  condition.  Basing  my 
remarks  upon  the  16  cases  I  should  state  that  the  disease  has  never 
occurred  earlier  than  ten  days  following  an  operation,  nor  later  than 
twenty-eight  days.  When  it  follows  operation  it  usually  develops 
in  from  ten  to  eighteen  days,  and  is  insidious  in  its  onset.  There  are 
practically  no  symptoms  save  an  increased  acceleration  of  the  pulse 
without  a  rise  of  temperature,  or  with  practically  none,  until  the 
patient  complains  of  stiffness  and  soreness  about  the  lower  extremi- 
ties, with  some  pain  along  the  line  of  the  vessels.  Oa  investigation  it 
was  found  that  more  or  less  induration  could  be  felt  along  this  line, 
and  a  peculiar  rope-like  feel  could  be  distinguished  which  apparently 
extended  above  Poupart's  ligament,  the  tenderness  being  traced 
upward  above  this  point.  Therefore,  the  diagnosis  would  be  based 
(i)  upon  the  increased  pulse  rate  without  a  corresponding  rise  of 
temperature,  there  seeming  to  be  some  circulatory  disturbance  which 
increased  the  pulse  rate  without  affecting  the  temperature;  (2)  the 
feeling  of  indefinite  distress  in  the  extremity  ;  (3)  the  induration  along 
the  lines  of  the  vessel  extending  above  Poupart's  ligament.  The  prog- 
nosis in  these  16  cases  has  been  good  so  far  as  other  complications  are 
concerned  and  loss  of  life,  as  they  all  recovered.  None  of  the  large 
number  of  reported  complications  of  such  cases,  such  as  thrombosis 
and  pulmonary  infarction,  occurred  in  these  cases.  However,  there  is 
this  much  to  be  said  :   there  is  more  or  less  disability  and  disturbance 


PHLEBITIS    FOLLOWING    ABDOMINAL    OPERATIONS.         235 

of  function.  This  may  amount  to  an  inability  to  use  the  limb  well, 
or  sometimes  necessitates  the  use  of  crutches  for  the  first  three  months 
after  operation.  In  one  case  more  or  less  disability  existed  for  a 
year,  the  patient  being  compelled  to  wear  elastic  bandages. 

Dr.  W.  J.  Mavo,  of  Rochester,  Minn. 

I  was  very  much  interested  in  this  paper  and  also  in  Dr.  Fowler's 
remarks.  For  about  two  years  I  have  had  this  matter  under  observa- 
tion, and  I  have  made  some  investigations  in  the  cases  I  have  had.  In 
that  time  we  have  met  something  over  12  cases,  which  has  been  about 
I  per  cent,  of  the  number  of  abdominal  cases  in  the  hospital,  and  there 
were  some  queer  things  brought  out  by  this  study.  The  most  impor- 
tant point  that  I  wish  to  make  is  in  connection  with  the  question  of 
pulmonary  embolus.  Three  cases  of  pulmonary  embolus  occurred 
during  this  time,  one  dying  and  two  recovering,  though  they  were  in  a 
very  dangerous  condition.  In  the  two  cases  that  recovered  the  acci- 
dent happened  before  the  time  of  phlebitis,  and  both  of  them  were 
followed  by  phlebitis.  One  came  on  the  fifth  and  the  other  on  the 
tenth  day,  the  embolus,  as  I  have  said,  preceding  the  phlebitis.  The 
case  of  embolus  that  died  had  a  firm  and  steady  pulse  up  to  the  time 
of  death,  showing  that  the  heart  had  continually  forced  the  blood 
into  the  lung.  In  the  two  that  recovered  the  heart  was  exceedingly 
weak,  undergoing  rapid  dilatation,  and  it  was  this  weakness  that  en- 
abled them  to  tide  over.  The  strength  of  the  heart  in  the  case  that 
died  practically  prevented  recovery.  I  do  not  think  that  phlebitis  is 
necessarily  confined  to  pelvic  cases,  as  I  had  one  following  a  simple 
gall-bladder  operation,  and  we  see  many  following  simple  appen- 
dectomies. 

I  am  not  able  to  state  why  the  condition  is  more  frequent  on  the 
left  side  than  on  the  right,  but  it  seems  to  be  so,  although  we  had 
three  cases  in  which  the  right  limb  was  involved,  and  two  in  which 
both  limbs  were  affected. 

Dr.  Turner,  of  Baltimore. 

I  would  like  to  ask  Dr.  Vander  Veer  if  the  condition  of  phlebitis 
has  been  noted  in  operations  for  hemorrhoids. 

Dr.  Vander  Veer.  Replying  to  the  remarks  of  Dr.  Turner,  I  would 
state  that  the  tumor  in  my  case  was  not  quite  as  large  as  my  fist,  and 
rested  closely  upon  the  vena  cava,  but  no  hemorrhoids  were  present. 


236       PHLEBITIS     FOLLOWING    ABDOMINAL     OPERATIONS. 

I  was  very  much  interested  in  the  remarks  of  Dr.  Fowler  and  Dr. 
Mayo.  A  year  ago  last  March  my  assistant  looked  up  the  number  of 
celiotomies  that  had  been  done  in  the  Albany  Hospital,  and  found 
that  my  own  numbered  about  1500.  Aside  from  the  case  to  which  I 
referred  that  died,  none  others  had  attracted  our  attention  as  to 
venous  thrombosis ;  therefore,  the  cases  two  years  ago  rather  startled  us. 
The  rarity  of  the  lesion  and  the  want  of  instructive  pathology  were 
the  two  points  that  I  especially  wanted  to  bring  out  to  day. 

Dr.  Frederick  Lange,  of  New  York. 

As  to  the  prognosis  of  those  cases  in  which  phlebitis  of  the  lower 
extremity  becomes  apparent,  my  experience  coincides  essentially  with 
what  has  been  said,  but  I  have  to  report  two  cases  of  death  from  pul- 
monary embolus  after  extirpation  of  large  fibroids.  They  were  cases 
in  which  there  was  every  reason  to  assume  that  they  would  take  a 
normal  course  to  recovery ;  but  each  one,  at  the  end  of  the  first  week, 
succumbed  in  a  few  hours  to  the  characteristic  heart  symptoms  of 
embolism. 

The  formation  of  thrombi  in  such  cases  is  certainly  favored  by  the 
slow  blood-current  in  the  much  dilated  and  ligated  veins,  and  needs 
not  to  be  caused  by  infection.  On  the  contrary,  I  am  inclined  to 
assume  that  a  certain  degree  of  inflammation  may  give  some  protec- 
tion against  embolism  by  greater  adhesion  of  the  thrombus  to  the 
wall  of  the  vessel.  My  fatal  cases  had  not  presented  any  symptoms 
of  inflammation.  On  the  other  hand,  I  do  not  remember  a  case  of 
death  among  those  cases  in  which,  with  progressing  thrombosis,  one 
could  speak  of  a  phlebitis  of  the  lower  extremities. 


TRAUMATIC     ARTERIO-VENOUS     ANEURISMS     OF 
THE    SUBCLAVIAN   VESSELS,   WITH    AN   ANA- 
LYTICAL  STUDY  OF   FIFTEEN'    REPORTED 
CASES,    INCLUDING   ONE   OPERATED. 

By  RUDOLPH  MATAS.  M.D., 

NEW   ORLEANS,   LA. 


Synopsis :  A  case  of  traumatic  {gufishot)  arterio  venous  aneutis?n  of 
the  right  subclavian  vessels,  involving  the  artery  within  the  scaleni ; 
division  of  the  atiery  between  ligatures  placed  on  the  first  and  third 
divisions  ;  detachment  of  the  anastomotic  confiection  ;  lateral  suture  of 
the  venous  orifice  ;  osteoplastic  resection  of  the  clavicle  under  eucain  B. 
ancesthesia ;  recovery,  with  partial  loss  of  hand  aftd  forearm  from 
arterial  ischcemia.  On  September  8th,  Moise  Miller,  a  young  Arcadian 
habitant  (farmer),  native  of  Rayne,  Arcadia  Parish,  La.,  was  brought 
to  me  for  treatment  at  the  New  Orleans  Sanitarium.  His  attending 
physician,  Dr.  C.  H.  Power,  of  Rayne,  who  kindly  referred  him  to 
me  and  accompanied  him  to  the  sanitarium,  gave  the  following  par- 
ticulars of  his  history  and  of  the  circumstances  under  which  the  injury 
was  inflicted.  We  may  premise  the  history  of  the  injury  by  stating 
that  he  is  a  robust  and  exceptionally  healthy  man,  aged  twenty-four 
years,  married.  He  is  broad-chested,  muscular,  frugal,  and  temperate  ; 
very  calm,  collected,  and  courageous.  In  health  he  weighs  165  to  170 
pounds,  and  is  six  feet  in  height.     He  is  very  industrious  and  active, 

'  While  this  article  is  in  press  two  additional  observations  of  arterio-venous  aneurisms 
involving  the  subclavian  vessels  have  been  reported  by  MM.  Gallois  and  Piollet,  of 
Lyons,  in  a  contribution  on  vascular  injuries  caused  by  simple  fractures  of  the  clavicle. 
("  Les  dechirures  vasculaires  par  fractures  fermees  de  la  clavicule,"  etc.,  in  Revue  de 
Chirurgie,  Paris,  No.  7,  21  annee,  July  10,  1901.)  These  observations,  together  with  the 
case  of  Vasilyeff  (ulceration  of  both  vessels  in  abscess  cavity),  have  reached  me  too  late 
to  be  incorporated  in  the  text,  but  will  be  found  in  the  final  table  of  the  reported  cases, 
which  epitomizes  the  history  of  seventeen  cases  of  arterio-venous  aneurisms  of  the  sub- 
clavian vessels,  instead  of  the  original  fifteen  tabulated  up  to  the  date  of  the  meeting. 


238  MAT  AS, 

and  has  always  been  engaged  in  out- door  pursuits.  His  past  history 
and  that  of  his  parents,  who  are  living,  reveals  no  antecedents  which 
bear  upon  his  present  troubles. 

On  Monday,  September  3,  1900,  six  days  before  his  arrival  at  the 
sanitarium,  and  while  attending  a  country  festival  near  his  home  in 
Rayne,  he  became  engaged  in  a  personal  difficulty  at  about  8  p  m. 
In  the  struggle  that  followed  he  succeeded  in  throwing  his  antagonist 
to  the  ground,  and  while  holding  him  down  with  both  hands  the  lat- 
ter drew  a  revolver  from  his  pocket,  and,  raising  it,  pressed  the  muzzle 
close  to  Miller's  chest  and  fired. 

Immediately  after  the  shot  he  (Miller)  felt  the  grip  of  his  right  hand 
relax  and  realized  that  his  arm  had  been  paralyzed.  The  spectators 
in  the  meantime  parted  the  combatants,  and  Miller  was  at  once  driven 
in  a  buggy  to  Dr.  Power's  residence,  a  distance  of  one  mile.  Though 
very  weak,  the  patient  stepped  out  of  the  buggy  without  assistance 
and  walked  a  few  steps  into  Dr.  Power's  office,  when  the  latter  saw 
him,  about  forty  minutes  after  the  shooting.  After  a  hasty  examina- 
tion, sufficient  to  convince  the  doctor  that  the  injury  was  of  a  very 
serious  character,  he  applied  a  compress  of  iodoform  gauze  over  the 
wound  and  secured  this  in  place  with  adhesive  plaster.  The  blood 
had  soaked  through  the  patient's  clothing  and  was  still  flowing  out  of 
the  orifice  of  penetration  when  Dr.  Power  applied  the  compress.  The 
bullet  wound  was  small,  however,  and  this  moderate  pressure  succeeded 
in  arresting  the  bleeding,  though  it  was  evident  by  the  rising  swelling 
in  the  neck  that  a  concealed  hemorrhage  was  now  progressing  actively 
in  the  neck.  After  a  few  minutes'  delay  the  patient  was  helped  to  his 
buggy  and  conveyed  to  his  home,  a  distance  of  one  mile,  where  he 
was  at  once  put  to  bed  and  an  ice-bag  applied  over  the  injured  area. 
At  no  time  did  the  patient  lose  consciousness,  and  it  was  not  until 
he  had  reached  his  home  that  he  showed  signs  of  great  prostration  and 
shock,  which  became  intensified  as  the  night  advanced  and  the  swell- 
ing in  the  neck  and  shoulder  increased. 

At  the  examination,  made  early  that  night  at  the  patient's  home, 
Dr.  Power,  in  consultation  with  Dr.  Webb,  ascertained  the  following 
facts :  The  patient  had  been  wounded  by  a  revolver  bullet  (Smith  & 
Wesson,  38  calibre), which  had  penetrated  in  the  right  second  intercostal 
space  about  three  inches  from  the  right  margin  of  the  sternum.  The 
bullet  had  ranged  obliquely  upward  and  backward,  inclining  slightly 
toward  the  right,  evidently  passing  under  the  clavicle  without  fractur- 
ing the  bone,  and   finally  lodging  under  the  skin  at  a  point  corre- 


i 


TRAUMATIC    ARTERIO -VENOUS    ANEURISMS.  239 

spending  to  the  anterior  border  of  the  trapezius,  midway  between  the 
mastoid  and  the  acromion,  where  it  could  be  felt  distinctly  by  the  touch. 
A  large  swelling  had  formed  in  the  neck  immediately  after  the  injury. 
This  was  caused  by  a  large  hsematoma,  which  extended  from  the 
shoulder  to  the  angle  of  the  jaw  laterally  and  from  the  second  rib 
to  the  scapular  region  anteroposteriorly.  All  external  bleeding  had 
stopped  and  only  a  bloody  ooze  stained  the  dressings.  The  skin  for 
some  distance  around  the  bullet  wound  was  powder  stained  and  burnt. 
The  most  notable  sign  that  attracted  the  attention  of  the  attending 
physician  at  this  time  (not  more  than  two  hours  after  the  injury)  was 
the  "intense  throbbing  or  pulsation  which  was  perceptible  in  the 
swelling  on  the  chest  and  neck,  and  a  loud  thrill,  which  could  be  felt 
along  the  course  of  the  subclavian  vessels,  extending  over  the  neck  up 
to  the  angle  of  the  jaw  and  down  the  shoulder  and  upper  arm."  The 
pulse  in  the  arteries  of  the  right  arm  was  absent.  It  was  also  noticed 
that  the  arm  on  the  opposite  side  was  motionless  and  anaesthetic  all 
over  th^  hand  and  forearm.  Evidently  there  had  been  a  coincident 
lesion  of  the  brachial  plexus. 

The  general  condition  of  the  patient  had  grown  worse  since  his 
return  home.  Coincidently  with  the  development  of  the  swelling 
and  aneurismal  signs,  he  had  become  weaker ;  he  now  showed  positive 
signs  of  shock  and  profound  exhaustion  ;  he  was  cadaverically  pale 
and  the  skin  was  covered  with  a  profuse  perspiration.  The  pulse  on 
the  sound  side  was  rapid  and  small.  He  had  lost  a  considerable  quan- 
tity of  blood  (sufficient  to  soak  through  his  clothing)  immediately 
after  his  injury,  but  this  had  ceased  readily  under  slight  pressure  with 
the  gauze  pad  applied  by  Dr.  Power.  It  was  evident,  therefore,  that 
this  condition  of  progressive  shock  was  due  to  the  concealed  bleeding 
in  the  hsematoma.  A  compress  was  reapplied  over  the  wound,  and 
this  again  was  covered  with  the  ice-bag.  By  midnight  (four  hours 
after  the  affray)  the  patient  was  so  completely  collapsed  that  he  was 
believed  to  be  moribund,  and  no  hope  was  entertained  of  his  recovery. 
He  remained  in  this  apparently  dying  condition  until  noon  of  the 
following  day  (September  4th),  sixteen  hours  after  the  injury,  when 
the  first  signs  of  improvement  were  noticed  and  the  patient  began  to 
rally.  With  this  improvement  the  enormous  swelling  in  the  neck  began 
to  harden  and  contract,  though  the  pulsation  and  thrill  remained  un- 
changed. 

Dr.  Power  then  states  that  the  patient's  temperature  was  above  nor- 
mal and  fluctuated  daily  (September  4th  to  8th)  from  100°  in  the  morn- 


240  M  A  T  A  S  , 

ing  to  103°  in  the  evening.  By  absolute  rest,  diet,  careful  stimulation, 
and  watchful  nursing  the  patient  continued  to  gain  strength,  though 
slowly.  It  was  noticed,  however,  that  the  throbbing  and  thrill  in 
the  supraclavicular  swelling  continued  to  grow  more  diffuse  and  in- 
tense as  the  swelling  diminished.  No  notable  improvement  was  ob- 
served in  the  condition  of  the  arm,  which  continued  to  be  "  of  no  use 
to  the  patient"  and  remained  pulseless  at  the  wrist  and  in  the  arm. 
This  was  Miller's  condition  when  he  was  brought  to  the  sanitarium 
in  New  Orleans  on  September  8,  1900. 

When  I  called  to  see  him  he  was  lying  in  bed,  still  extremely  pale 
and  exhausted  from  his  long  journey  and  the  exertion  involved  in 
transportation  from  the  train  to  the  institution.  His  expression  was 
anxious,  and  there  was  some  complaint  of  pain  in  the  neck.  The  right 
pulse,  which  had  disappeared  completely,  was  felt  at  the  wrist  very 
faintly  to-day  for  the  first  time  (fifth  day  after  injury),  showing  some 
re-establishment  of  the  collateral  circulation.  At  11.30  a.m.,  when  the 
patient  was  admitted,  his  temperature  was  98.8°,  but  in  the  evening  it 
rose  to  101°,  with  a  pulse  of  no  and  respiration  22. 

Upon  examining  the  patient  I  first  observed  a  dark  circular  slough, 
the  size  of  a  silver  quarter,  in  the  skin  over  the  right  second  inter- 
costal space,  about  three  inches  from  the  sternum.  Numerous  inflamed 
powder  stains  sprinkled  the  skin,  testifying  to  the  close  proximity  of 
the  pistol  when  fired.  The  entire  supraclavicular  region  is  swollen,  also 
the  region  of  the  trapezius,  entirely  obliterating  the  normal  outlines 
of  the  clavicle;  in  the  neck  a  space  as  large  as  the  palm  of  the  hand 
is  bluish-black  from  extensive  ecchymosis.  The  centre  of  this  spot  is 
particularly  dark  and  corresponds  to  the  site  of  the  bullet,  which  can 
be  felt  distinctly  movable  in  a  bed  of  semi-fluid  haematoma.  The  skin 
of  the  entire  supraclavicular  region  from  the  angle  of  the  jaw  to  the 
shoulder  on  the  right  side  is  discolored  from  the  deep  subcutaneous 
extravasation.  There  is  a  very  distinct  subcutaneous  heaving  pulsation, 
this  being  most  marked  along  the  course  of  the  subclavian  vessels  and 
the  right  internal  jugular  vein.  This  vessel  swells  and  fills  up  the 
suprasternal  space  with  each  beat  of  the  heart.  The  superficial  veins 
of  the  neck  and  arm,  the  cephalic  and  basilic  veins  down  to  the  elbow 
are  all  unusually  prominent,  and  their  dark-bluish  color  stands  in 
conspicuous  relief  against  the  unusually  pale,  waxy  skin.  On  palpa- 
tion there  is  marked  pitting  on  pressure  from  oedema,  over  the  clavicle 
and  the  entire  supraclavicular  region ;  the  general  pulsation  seen  over 
the  supraclavicular  region   is   distinctly  confirmed   by  palpation.     A 


Arterio-venous  Aneurisms  of  the  Subclavian  Vessels.     Case  of  M.  M. 
Photograph  taken  seven  months  after  operation,  showing  scar  of  incision  in  neck  after 
resection  of  clavicle,  etc.,  and  condition  of  arm  and  hand  after  healing.     (Scar-lines  have 
been  purposely  intensified  in  plate  to  show  lines  of  incision  more  plainly.) 


TRAUMATIC     A  RT  E  R  I  O-V  E  N  O  US     ANEURISMS.  24I 

widely  diffused  and  intense  purring  thrill  can  be  felt  by  the  most 
superficial  contact  with  the  surface  all  over  the  neck,  and  more  espe- 
cially over  the  subclavian,  jugular,  cephalic,  and  basilic  veins.  The 
thrill  appears  to  be  transmitted  in  all  directions  from  its  point  of 
greatest  intensity,  immediately  above  the  middle  third  of  the  clavicle, 
all  along  the  venous  currents  of  the  neck  and  arm  as  low  down  as  the 
right  hand.  The  most  striking  phenomenon  is  the  peculiarly  loud 
murmur  which  is  heard  all  over  the  neck,  chest,  and  arm,  along  the 
course  of  the  venous  trunks.  This  murmur  is  difficult  to  describe  ;  it 
is  a  continuous  hum,  with  diastolic  whirring  accentuations,  and  is 
heard  with  greatest  intensity  over  the  middle  of  the  clavicle,  and  is 
harsh,  buzzing,  and,  in  fact,  indescribable.  Several  odd  comparisons 
were  made  by  those  who  heard  it,  but  no  description  or  analogy  ap- 
pears to  give  an  accurate  idea  of  its  extraordinary  peculiarities.  This 
murmur  is  so  loud  that  it  can  be  heard  by  listening  attentively  at  a 
distance  of  nearly  one  inch  from  the  surface. 

This  murmur,  like  the  thrill,  is  propagated  with  greatest  intensity 
along  all  the  venous  trunks  from  the  bend  of  the  elbow  to  the  innomi- 
nate veins  and  superior  vena  cava.  It  can  be  heard  distinctly  over 
the  facial  and  temporal  veins.  Its  vortex  or  loudest  point  is  over  an 
area  the  size  of  a  silver  dollar,  situated  just  above  the  middle  third  of 
the  clavicle,  in  the  very  centre  of  the  bullet  tract,  and  evidently  in  a 
line  with  the  subclavian  vessels. 

In  spite  of  all  this  tremendous  vascular  upheaval  and  disturbance, 
the  work  of  repair  was  evidently  progressing  steadily  in  a  favorable 
direction.  The  swelling  of  the  original  area  had  on  the  ninth  day 
markedly  subsided ;  the  extravasation  was  being  absorbed,  and  it  was 
evident  that  the  large  stream  of  blood  which  was  being  poured  out  of 
the  artery  had  found  a  direct  outlet  in  the  veins;  these  had  accom- 
modated themselves  to  the  abnormal  pressure,  and  were  carrying  off 
the  overflow  through  comparatively  safe  channels  back  again  into  the 
circulation.  Associated  with  these  evidences  of  vascular  disturbance 
there  still  remained  a  marked  paresis  of  the  entire  right  arm  down  to 
the  fingers.  The  arm  could  be  moved  slightly  by  strong  voluntary 
efforts,  but  pronation  and  supination  were  impossible,  the  arm  usually 
remaining  motionless,  extended  and  passive  by  the  side  of  the  body, 
or  it  remained  inert  in  which  ever  position  it  happened  to  be  placed 
by  the  patient's  left  arm  or  by  the  hands  of  the  attendants. 

The  sensibility  was  impaired  all  over  the  arm  up  to  the  shoulder, 
but  sensation  could  be  elicited  by  deep  pricking  with  pins  over  the 


242  MATAS, 

fingers  and  hand  on  the  palmar  and  dorsal  surfaces.  The  thermic 
sense  was  also  greatly  impaired,  but  the  application  of  very  hot  water 
to  the  hand,  as  in  washing  this  part,  elicited  some  sensation  on  the 
part  of  the  patient.  The  condition  was  really  one  of  parsesthesia  and 
paresis  rather  than  paralysis,  and  this  encouraged  the  belief  that  the 
injury  to  the  brachial  plexus  was  a  contusion  and  partial  laceration 
rather  than  an  actual  division  of  its  constituent  trunks. 

Diagnosis.  By  summarizing  the  evidence  thus  clearly  presented  the 
following  points  were  determined  :  i.  That  the  course  and  direction 
taken  by  the  bullet  indicated  that  the  missile  had  penetrated  the  neck 
by  passing  under  the  clavicle  without  injuring  it,  had  crossed  the  path 
of  the  subclavian  vessels  just  about  where  the  scalenus  anticus  crosses 
the  artery,  and  after  injuring  both  artery  and  vein  had  grazed  and 
contused  the  brachial  plexus. 

2.  The  immediate  cessation  of  the  radial  pulse  at  the  time  of  the 
injury,  which  continued  to  be  imperceptible  until  the  fifth  day,  and 
the  coldness  of  the  skin  and  pallid  appearance  of  the  arm,  indicated 
that  the  circulation  in  the  subclavian  had  been  interrupted  by  the 
injury. 

3.  The  positive  and  pathognomonic  signs  of  arterio-venous  aneurism 
or  varix,  i.  e.,  the  continuous  venous  hum  plus  the  rasping,  buzzing 
double  murmur  heard  with  greatest  intensity  in  the  diastolic  period 
(Broca  and  Wahl's  signs),  the  intense  vibratory  purring  thrill  {fre- 
missement  caiaire),  propagated  like  a  murmur  at  a  great  distance  along 
the  venous  channels  on  the  proximal  and  distal  sides  of  the  point  of 
injury. 

4.  The  spontaneous  arrest  of  the  bleeding  shortly  after  the  first 
primary  hemorrhage,  the  absence  of  secondary  bleeding,  and,  above 
all,  the  rapid  subsidence  of  the  haematoma  while  the  intensity  of  the 
physical  signs  of  aneurism  were  increasing ;  the  great  fulness,  pulsa- 
tion, and  distention  of  the  cervical  and  brachial  veins,  more  espe- 
cially during  the  diastolic  period — all  clearly  pointed,  in  fact,  demon- 
strated, that  the  subclavian  artery  and  vein  had  been  simultaneously 
injured  by  the  bullet,  the  perforation  leading  to  the  almost  immediate 
formation  of  an  arterio-venous  anastomosis. 

It  also  appeared  to  be  most  probable  that  the  anastomosis  was  a 
direct  one  (aneurismal  varix)  and  not  through  an  intermediary  sac 
(varicose  aneurism),  though  this  point  could  not  be  positively  de- 
termined at  the  time  in  consequence  of  the  swelling  above  and  under 
the  clavicle  in  the  neighborhood  of  the  bullet  tract.     There  was,  how- 


TRAUMATIC    A  RTE  R  I  O- VEN  O  US    ANEURISMS.  243 

ever,  no  distinct  globular  or  especially  defined  swelling.  There  was 
only  a  general  hard  swelling  over  the  supraclavicular  space  filling  the 
lateral  aspect  of  the  neck  as  with  a  mass  of  recent  exudates  and  extra- 
vasated  products,  all  masked  by  a  dense,  doughy  oedema  of  the  skin. 
At  first  the  entire  supraclavicular  region  appeared  to  expand  and  pul- 
sate as  a  whole,  all  over,  with  each  beat  of  the  heart ;  but  latterly,  as 
the  swelling  diminished,  the  pulsation  was  more  defined  and  distributed 
most  intensely  along  the  veins  embedded  in  the  mass  of  exudates. 

Having  sufficiently  disposed  of  the  question  of  diagnosis,  we  were 
now  ready  to  consider  the  more  serious  problem  of  treatment.  What 
were  the  indications  furnished  by  this  remarkable  and  rare  lesion?  If 
we  bear  in  mind  the  fact  that  the  patient  had  come  to  us  for  treat- 
ment on  the  fifth  day  after  injury,  and  was  still  suffering  from  the 
shock  and  anaemia  incident  to  the  primary  injury,  and  that  the  eschar 
existed,  we  will  realize  that  we  had  reason  to  consider  the  possible 
dangers  that  menaced  this  patient  from  two  points  of  view:  First,  the 
possibility  of  secondary  hemorrhage  ;  second,  the  remote  dangers  in- 
cident to  the  formation  of  a  secondary  or  consecutive  aneurism  of  the 
artery  proper,  with  all  its  attendant  train  of  evils  and  dangers.  As  to 
the  immediate  dangers  of  possible  infection  and  secondary  hemor- 
rhage, we  were  soon  able  to  satisfy  ourselves  that  they,  at  least,  could 
be  safely  eliminated  by  a  careful  observation  of  the  patient's  con- 
dition during  the  first  four  days  that  followed  his  admission  to  the 
sanitarium. 

From  the  moment  that  the  patient  was  admitted  to  the  institution 
the  injured  surface  was  subjected  to  the  most  careful  antiseptic  treat- 
ment and  methodical  compression  with  bandages  and  ice-bags.  The 
whole  region  was  carefully  washed  with  potash  soap  and  lysol  solution 
(i  per  cent.),  followed  by  alcohol.  Wet  antiseptic  compresses  were 
applied,  and  the  whole  supraclavicular  region  and  lateral  surfaces  of 
the  neck  were  subjected  to  vigorous  compression  with  a  spica  bandage, 
over  which  an  elastic  woven  bandage  was  adjusted,  and  over  this  a 
large  ice-bag  was  applied.  This  firm  elastic  compression,  with  the 
addition  of  cold,  promoted  the  absorption  of  exudates  and  extrava- 
sated  products,  and  we  hoped  also  that  it  would  help  to  moderate  the 
violence  of  the  strain  that  was  being  constantly  forced  upon  the  veins 
through  the  aneurismal  orifice.  With  these  simple  measures,  aided 
by  absolute  rest,  a  light  nutritious  dietary,  consisting  chiefly  of  milk, 
fruit,  broths,  and  cereals,  and  other  hygienic  measures,  the  robust  na- 
ture of  the  patient  soon  asserted  itself.     The  temperature,  which  upon 


244  MATAS, 

admission  had  oscillated  between  ioi°  and  102°  F,,  gradually  sub- 
sided, so  that  by  the  fourth  day  (ninth  after  injury)  it  rose  no  higher 
than  99°.  The  pulse  likewise  moderated  in  frequency,  and  fell 
to  84-90.  The  discoloration  of  the  surface  rapidly  diminished,  the 
dark  bluish-black  area  of  extravasation  being  limited  to  the  spot  occu- 
pied by  the  bullet.  The  eschar  at  the  wound  of  entrance  fell  off 
September  nth  (eighth  day  after  injury),  leaving  behind  a  healthy, 
granulating  surface.  The  pain  and  superficial  tenderness  over  the  neck 
and  chest  diminished  daily;  the  cedema,  which  had  completely  ob- 
literated the  clavicle  and  all  the  surface  anatomy  of  the  region,  now 
subsided,  and  the  clavicle  was  easily  outlined  under  the  thin  skin.  It 
was  evident  from  all  these  signs  of  improvement  that  the  danger  of 
infection  which  we  had  first  apprehended  from  the  fever,  the  pain  and 
the  tenderness  over  the  parts,  could  now  be  definitely  eliminated. 
And  as  there  was  no  oozing  at  the  point  of  entrance  or  other  warnings 
of  secondary  bleeding,  I  now  felt  encouraged  to  believe  that  this  grave 
source  of  apprehension  would  also  soon  be  eliminated.  On  the  other 
hand,  the  physical  signs  of  the  aneurism  became,  if  anything,  more 
pronounced  as  the  cedema  of  the  skin  subsided.  The  hum,  murmur, 
and  thrill  became  more  noisy  and  turbulent,  and  could  be  studied  to 
still  greater  advantage  as  the  vessels  approached  the  surface.  The 
swelling  and  turgidity  of  the  jugular  and  brachial  veins  also  became 
more  perceptible.  The  pulsation  in  the  internal  jugular  was  most 
striking.  With  every  beat  of  the  heart  this  vessel  pulsated  so  forcibly 
and  became  so  distended  that  it  filled  the  entire  suprasternal  and  pre- 
tracheal space,  thus  demonstrating  that  while  the  venous  system  had 
accommodated  itself  to  the  new  conditions,  and  was  standing  the 
great  strain  imposed  upon  it  by  the  sudden  shunting  or  short-cir- 
cuiting of  the  arterial  current,  it  was  unavoidable  to  conclude  that  a 
condition  of  permanent  overdistention  and  engorgement  was  laying 
the  foundation  for  future  evil.  The  paralysis  of  the  arm  still  con- 
tinued ;  there  was  a  slight  improvement  in  the  movements  of  the  arm, 
and  the  sensibility  of  the  skin  was  more  acute,  but  apart  from  this  the 
arm  remained  lifeless  and  inert  by  the  patient's  side. 

For  the  moment  all  fear  of  immediate  complications  could  be 
dismissed,  though  we  realized  that  fully  three  weeks  after  heal- 
ing would  have  to  elapse  before  we  could  safely  state  that  the 
danger  of  secondary  hemorrhage  could  be  entirely  eliminated. 
(See  Will's  case,  secondary  hemorrhage  after  healing  of  wound, 


TRAUMATIC     A  RT  E  R  I  O-V  EN  O  US     ANEURISMS.  245 

causing  death  three  weeks  after  injury.)  As  the  patient  resided 
in  an  isolated  settlement  in  the  country,  and  could  not  remain 
long  under  our  observation,  the_  question  that  arose  was, 
"  Should  the  patient  be  allowed  to  return  home,  with  instruc- 
tions to  return  again  for  further  treatment  in  the  event  that 
other  serious  developments  should  follow;  or  was  it  the  wiser 
plan  to  offer  him  the  opportunity  of  anticipating  the  complica- 
tions and  dangers  that  the  future  might  have  in  store  for  him, 
by  proceeding  to  an  early  and  radical  attempt  to  rid  him  of  this 
dangerous  lesion  under  the  most  favorable  conditions  of  surgical 
preparation  ? 

While  the  question  involved  many  debatable  propositions, 
which  will  be  more  appropriately  discussed  in  another  section 
of  this  contribution,  I  will  state  that  in  view  of  the  progressive 
improvement  in  the  general  condition  of  the  patient,  and  the 
probability  that  he  would  escape  the  dangei-s  of  secondary  hem- 
orrhage and  other  immediate  complications,  I  had  concluded, 
in  accordance  with  the  classical  recommendations  on  the  subject, 
that  I  would  abstain  from  all  operative  intervention,  and  would 
allow  the  patient  to  return  home  after  the  wound  had  healed 
completely.  Had  I  known  the  exact  anatomical  relations  of 
the  aneurismal  orifice,  which  were  only  determined  at  the  time 
of  the  operation,  I  would  have  made  a  special  trial  of  systematic 
digital  compression  over  the  anterior  scalene  after  all  the  acute 
reactionary  swelling  had  subsided.  But  even  with  the  favorable 
position  of  the  anastomotic  orifice  (immediately  in  the  lowest 
centre  of  the  scalene  tendon),  it  is  very  doubtful  that  this  mode 
of  treatment  would  have  succeeded,  as  the  clavicle  was  directly 
in  the  way  of  effective  compression  ;  furthermore,  in  the  cases 
in  which  this  method  had  been  tried  it  had  failed  altogether, 
and  I  therefore  gave  it  little  consideration.  On  the  other  hand, 
the  patient,  who  had  been  profoundly  impressed  with  the  gravity 
of  his  injury,  reminded  me  insistently  that  he  would  not  be  able 
to  remain  in  the  city  for  observation,  or  to  return  again  at  some 
future  time  if  complications  should  arise,  without  a  great  sacri- 
fice— a  greater  sacrifice  than  his  limited  resources  would  allow. 
He  was  anxious  to  have  something  done  that  would  be  decisive 


246  M  A  T  A  S , 

and  that  would  relieve  him  permanently  of  the  worry  and  un- 
certainty of  a  lesion  which  he  might  tolerate  in  time,  but  would 
always  remain  a  menace  to  his  comfort  and  even  to  his  life. 

The  dangers  of  a  radical  operation  and  the  unusual  character 
of  such  an  operation  were  fully  explained  to  him,  but  he  pre- 
ferred to  take  his  chances,  provided  there  was  a  reasonable 
prospect  of  recovery  and  permanent  cure. 

The  determined  attitude  of  the  patient,  who  showed  himself 
as  fearless  as  he  was  determined,  coupled  with  our  serious  mis- 
givings as  to  the  final  outcome  of  the  case  if  allowed  to  drift 
along  its  natural  course,  led  me,  in  spite  of  my  grave  doubts  as 
to  the  wisdom  of  this  decision,  to  acquiesce  to  the  patient's 
courageous  appeal  and  to  give  him  the  benefit  of  the  operation. 

Without  underestimating  the  difficulties  that  were  to  be  en- 
countered, I  still  believed  that  by  adopting  a  carefully  prepared 
and  matured  plan  of  action  I  would  be  able  to  overcome  the 
chief  obstacles  in  the  way  of  a  safe  dissection  of  the  varix  and 
complete  control  of  its  anastomotic  orifice.  The  main  objects 
of  the  operation  that  were  kept  in  view  were  :  (i)  To  obtain  free 
and  easy  access  to  the  entire  injured  area  by  preliminary  osteo- 
plastic section  of  the  clavicle  from  its  outer  third  to  the  sterno- 
clavicular joint,  which  was  to  be  disarticulated  or  temporarily 
excised.  (2)  To  obtain  complete  provisional  control  of  the  sub- 
clavian circulation  by  applying  a  temporary  traction-loop  upon 
the  first  portion  of  the  subclavian  or  innominate  artery,  which 
by  lifting  the  vessel  from  its  bed  would  occlude  the  main  trunk 
and  its  most  important  collateral  branch,  the  vertebral.  (3)  To 
completely  explore  by  careful  dissection  the  point  of  anastomotic 
communication  existing  between  the  subclavian  artery  and  vein. 
(4)  To  permanently  control  the  subclavian  artery  over  the  distal 
and  proximal  side  of  the  anastomosis  by  ligature,  and  (5)  to  pro- 
visionally clamp  or  ligate  the  vein  above  and  below  the  venous 
orifice  as  a  preliminary  to  the  extirpation  of  an  intervening  sac 
that  might  exist  between  the  vessels.  Then  (6),  if  possible,  to 
suture  the  venous  orifice  by  lateral  phleborrhaphy,  thus  allowing 
the  venous  circuit  of  the  upper  extremity  to  be  re-established 
after  the  removal  of  the  temporary  clamps  or  ligatures  on  the 


TRAUMATIC    A  RTE  R  I  O-VENO  US    ANEURISMS.  247 

vein.  (7)  To  restore  the  parts  to  their  normal  condition  by 
wiring  the  divided  clavicle  into  position.  Incidentally,  and  as 
a  minor  feature  of  the  operation,  the  bullet  would  be  extracted. 
That  this  desirable  but  difficult  programme  would  be  carried 
out  in  all  its  details  I  did  not  fully  anticipate,  but  I  did  expect 
to  accomplish  the  main  purpose  of  the  operation  if  I  once  suc- 
ceeded in  obtaining  a  complete  control  of  the  innominate  and 
obtain  a  free  and  open  field  for  the  manipulations  necessary  to 
dissect  the  anastomosis.  As  the  sequel  and  details  of  the  oper- 
ation show,  unexpected  anomalies  in  the  arterial  distribution 
and  the  freedom  of  the  collateral  supply  did  come  near  upset- 
ting my  plans  and  added  greatly  to  the  perils  of  the  patient. 
Nevertheless,  the  value  of  a  carefully  planned  operation  and 
thorough  preparation  for  emergencies  was  certainly  well  illus- 
trated in  this  case,  and  while  it  may  remain  a  debatable  ques- 
tion whether  a  procedure  of  this  kind  is  justifiable  in  just  such 
conditions  as  those  described  in  this  case,  it  cannot  be  denied 
that  the  final  result  obtained,  even  at  the  price  of  a  mutilation  of 
the  paralyzed  hand  and  arm,  is  far  more  satisfactory  (consider- 
ing the  specially  unfavorable  conditions  under  which  this  patient 
was  placed)  than  the  uncertainty  of  leaving  this  grave  lesion 
without  interference  to  the  care  of  nature  alone. 

Operation.  On  Thursday,  September  13,  igoo  (ninth  day  after 
the  injury),  after  all  preparations  had  been  completed,  and  with  the 
valuable  assistance  of  Drs.  H.  B.  Gessner,  S.  M.  D.  Clark,  John  Smyth, 
U.  Maes,  and  Dr.  Power,  who  acted  as  recorder,  the  operation  was 
undertaken.  The  operation  was  begun  at  9.20  a.m.,  and  it  was  2.30 
P.M.  (nearly  five  hours)  before  the  patient  was  taken  back  to  his  bed, 
though  the  actual  operative  work  did  not  consume  three  hours. ^ 

We  will  begin  the  narrative  of  the  operation  by  stating  that  in  an- 

1  Much  of  the  time  was  consumed  in  giving  the  patient  periods  of  rest,  especially 
during  the  local  anassthesia  stage  of  the  operation.  During  these  rest  periods,  as  is 
often  done  in  tedious  operations  under  local  anaesthesia,  the  patient  was  given  freely  of 
ice  water,  panopepton,  toddy,  and  even  beef  tea,  all  of  which  he  enjoyed  immensely,  and 
which  helped  him  greatly  to  control  himself.  Even  after  chloroform  had  been  adminis- 
tered he  was  never  fully  unconscious,  except  for  a  few  moments,  and  would  frequently 
rouse  up  to  call  for  ice  water  or  other  drinks,  which  were  given  to  him  liberally  without 
ever  exciting  nausea  or  vomiting. 


248  MAT  AS, 

ticipation  of  the  long  duration  of  this  operation  and  of  the  advantages 
that  would  be  gained  by  diminishing  the  risks  of  prolonged  saturation 
with  a  general  anaesthetic,  and  with  the  view  of  diminishing  the  tur- 
gescence  of  the  jugular  and  other  cervical  veins,  which  were  already 
greatly  distended,  and  would  be  likely  to  swell  still  more  under  gen- 
eral narcosis  and  vomiting,  I  decided  to  attempt  the  preliminary 
resection  of  the  clavicle  by  means  of  local  anaesthesia.  I  was  encour- 
aged in  this  by  the  calm  and  fearless  temperament  of  the  patient,  who 
showed  no  anxiety  in  the  contemplation  of  the  operation  or  of  his 
surroundings.  It  was  not  my  intention  to  perform  the  entire  opera- 
tion under  local  infiltration  anaesthesia,  but  simply  to  economize  the 
general  anaesthetic  by  adopting  infiltration  anaesthesia  during  the  first 
stages  of  the  operation,  viz.:  (i)  the  resection  of  the  clavicle,  and  (2) 
the  application  of  a  provisional  loop  around  the  innominate.  The  ad- 
vantages of  local  anaesthesia  during  these  two  important  stages  of  the 
operation  were  not  exaggerated,  as  we  found  subsequently,  because  we 
were  relieved  of  all  anxiety  and  annoyance  on  the  score  of  vomiting 
or  other  disturbances  in  breathing  from  cyanosis,  etc.,  which  might 
have  caused  a  great  turgescence  of  the  jugular,  subclavian,  and  innomi- 
nate veins  while  exploring  the  pretracheal  region  for  the  innominate 
artery.  As  it  was,  the  patient  gave  us  great  assistance  by  voluntarily 
changing  the  position  of  his  head  to  suit  our  needs  as  we  displaced 
the  distended  and  pulsating  venous  trunks  of  the  aneurismal  and  cervi- 
cal region.  The  stoicism  of  the  patient  under  these  circumstances, 
his  perfect  immobility  and  passiveness,  which  permitted  as  deliberate 
and  free  a  dissection  as  on  a  cadaver,  off"ered  a  truly  remarkable  spec- 
tacle worthy  of  the  greatest  respect  and  admiration. 

It  was  not  until  after  the  provisional  security  loop  had  been  placed 
upon  the  anomalous  subclavian,  and  after  a  long  and  tedious  search 
had  been  made  for  the  missing  innominate,  and  not  until  we  began 
to  encroach  upon  the  deep  branches  of  the  cervical  plexus,  which 
for  obvious  reasons  we  could  not  infiltrate,  that  he  began  to  complain 
of  pain,  and  we  at  once  proceeded  to  administer  chloroform.  This 
was  at  11.55,  ^  little  over  two  hours  after  the  beginning  of  the  opera- 
tion ;  the  general  anaesthetic  was  given  in  drop  doses  and  interrupt- 
edly from  11.56  to  1.30  (one  hour  and  thirty-four  minutes),  after 
which  it  was  discontinued  altogether.  It  should  now  be  stated  that 
twenty  minutes  before  beginning  the  operation  the  patient  was  given 
i^  gr.  morph.  sulph.  hypodermically,  which  is  usual  in  my  practice 
as  a  routine  procedure  in  all  large  local  ann^sthesia  operations. 


TRAUMATIC    A  RTE  R  I  O-V  ENO  US    ANEURISMS.  249 

In  order  to  describe  the  operation  systematically  it  will  be  divided 
into  the  following  stages  : 

First  Stage.  Section  of  the  clavicle  at  the  junction  of  the  middle  and 
outer  thirds. — For  this  purpose  the  skin  overlying  the  clavicle  and  all 
the  periosteal  tissue  were  densely  infiltrated  with  Schleich's  No.  i  so- 
lution 1/5  of  I  percent.,  eight  syringefuls,  each  containing  22  minims, 
being  used.  The  clavicle  was  denuded  of  its  periosteum;  two  drill 
holes  were  made  on  each  side  of  the  proposed  line  of  section  to  facili- 
tate wiring  at  a  later  stage,  and  the  bone  was  divided  with  a  Gigli 
saw. 

Second  Stage.  Formation  of  osteoplastic  clavicular  flap. — A  curvi- 
linear incision  extending  from  the  line  of  clavicular  section  two 
inches  below  the  clavicle,  including  the  points  of  penetration  of  the 
bullet,  and  carried  across  the  right  sternoclavicular  articulation  to 
the  middle  of  the  neck,  where  it  terminated  opposite  the  lower  border 
of  the  thyroid  cartilage. 

This  incision  was  made  painless  by  a  massive  infiltration  of  3)^  ozs. 
of  an  isotonic  saline  solution  of  eucain  B.  (i/io  of  i  per  cent.)  dis- 
solved in  0.8  per  cent,  salt  solution  along  the  whole  line  of  incision, 
causing  complete  cedema  of  the  infiltrated  points.  The  whole  surface 
was  covered  with  an  ice  and  salt  poultice,  which  was  kept  in  place 
eight  minutes.  The  skin,  subcutaneous  tissues,  and  clavicle  and  sterno- 
mastoid  tendon,  previously  mobilized  by  section,  were  now  elevated 
and  the  sternoclavicular  joints  disarticulated,  after  previous  peri-  and 
intra-articular  infiltration  of  the  tissues  of  joint  with  Schleich  No.  i 
(1/5  of  I  per  cent,  of  eucain  B.).  Some  pain  was  experienced  in  mak- 
ing traction  upon  the  tissues  of  the  neck  while  disarticulating. 

Third  Stage.  Dissection  and  elevation  of  osteoplastic  flap  formed  by 
clavicle,  skin,  sternomastoid,  and  subcutaneous  tissues. — The  flap  turned 
up  and  rolled  upon  itself,  exposing  the  deep  cervical  aponeurosis, 
the  sternohyoid  and  sternothyroid  muscles,  anterior  jugular  and  thy- 
roid veins,  all  large  and  pulsating ;  termination  of  the  cephalic  into 
subclavian  lost  in  a  mass  of  densely  infiltrated  tissues  and  exudates. 
Time,  10.45  ^•^'-  Pulse,  96,  good;  patient  cheerful,  but  tired. 
Very  little  bleeding  thus  far ;  few  ligations.  In  anticipation  of  more 
exhausting  work  a  hypodermic  of  i/ioo  gr.  digitalis  and  1/30  gr. 
strychnine  were  given,  with  a  glass  of  ice  water  and  2  ozs.  of  strong 
toddy.     After  an  interval  of  ten  minutes  of  rest,  operation  resumed. 

Fourth  Stage.  Exposure  and  preparatory  control  of  the  vetious  side 
of  the  atieurism. — In  view  of  possible  hemorrhage  from  traction  and 


250  MATAS, 

tearing  the  veins  while  elevating  the  osteo-cutaneous  flap  high  enough 
to  clearly  and  freely  expose  the  injured  vessels  in  the  region  of  the 
scalenes,  it  was  thought  the  better  plan  to  begin  this  stage  by  thor- 
oughly exposing  the  venous  side  of  the  aneurism.  The  subclavius 
muscle,  which  had  remained  in  the  wound,  on  account  of  the  close 
enucleation  of  the  clavicle,  was  now  divided  and  excised.  The 
cephalic  vein  was  exposed  and  followed  to  its  terminus  in  the  sub- 
clavian vein,  and  the  turgid  bunch  of  veins  formed  by  the  posterior 
scapular,  suprascapular,  transverse  cervical,  and  external  jugular  veins 
was  dissected  out  with  much  difficulty  on  account  of  dense  adhesions, 
and  traced  to  a  common  terminal  in  the  subclavian.  The  subclavian 
vein  was  now  identified,  but  not  without  some  delay,  because  it 
seemed  to  be  divided  into  two  very  distinct  parts,  one  on  the  axil- 
lary side  being  very  much  smaller  than  the  other.  This  small  axillary 
part  appeared  to  rise  up  in  the  neck,  where  it  could  be  traced  to  an 
ill-defined  mass  of  organized  exudates  and  extravasated  products, 
which  completely  masked  the  outlines  of  the  scalenes.  The  brachial 
plexus,  the  subclavian  artery,  and  anterior  scalene  were  all  inextrica- 
bly blended  in  the  mass,  which,  judging  by  the  pulsation  and  inten- 
sity of  the  purr  and  thrill,  must  be  the  seat  of  the  aneurismal  orifice. 
But  the  anatomical  characteristics  of  the  tissues  were  entirely  lost ; 
not  even  the  tendon  of  the  scalene  could  be  made  out,  as  it  was 
completely  incorporated  in  the  dense  and  resisting  mass  of  exudates. 
The  axillary  portion  of  the  subclavian  vein  appeared  to  have  been 
dragged  upward  into  this  mass,  forming  an  angle.  (See  diagram.)  In 
the  proximal  (cardiac)  side  the  subclavian  vein  formed  an  enormously 
distended  trunk,  which  crossed  over  the  first  rib  and  was  lost  behind  the 
sternohyoid  muscles,  where  it  united  with  the  internal  jugular.  The 
contrast  in  the  size  of  the  axillary  and  cervical  portions  of  the  subcla- 
vian was  remarkable,  and  could  only  be  accounted  for  by  the  formation 
of  a  valvular  projection  in  the  bend  of  the  vein,  where  it  inosculated  with 
the  artery.  Catgut  ligatures  were  now  placed  upon  all  the  tributaries 
of  the  subclavian  as  they  entered  into  the  axillary  side  of  the  vessel, 
and  a  provisional  silk  ligature,  not  tightly  drawn,  was  applied  to  the 
main  trunk  itself,  on  the  axillary  side,  a  short  distance  before  its 
entrance  into  the  mass  covering  the  scalenes.  The  distended  trunk 
of  the  subclavian  vein  on  the  proximal  side  was  now  dissected  care- 
fully at  a  distance  from  the  supposed  point  of  anastomosis,  in  readiness 
for  provisional  clamping  or  ligation  when  the  arterial  side  of  the 
aneurism  would  be  controlled.     It  was  evident  that  any  further  ob- 


TRAUMATIC    A  RT  E  R  I  O-V  EN  OUS    ANEURISMS.  25I 

stacle  placed  on  the  circulation  on  the  venous  side  without  previous 
arrest  of  the  arterial  circulation  would  have  led  to  such  strain  at  the 
anastomotic  opening  that  it  might  have  caused  its  premature  rupture. 
Fifth  Stage.  Exploration  in  search  of  the  innominate  and  provisional 
loop  around  anomalous  subclavian  applied. — The  arterial  trunks  on 
the  proximal  side  of  the  aneurism  were  now  explored  with  the  finger. 


Diagrammatic  representation  of  arterio- venous  communication  (after  excision  of  clavicle). 

1.  Scalenus  anticus. 

2.  Scalenus  medius. 

3.  Subclavian  vein.     The  arrows  show  direction  of  arterio-venous  current. 

4.  Internal  jugular  vein. 

5.  Innominate  vein. 

6.  Axillary  portion  of  the  subclavian  vein  much  reduced  in  size  as  a  result  of  angular 
traction  from  adhesion  of  vein  to  scalenus,  and  great  distention  of  proximal  side  of  vein 
with  arterial  blood  poured  in  by  artery. 

7.  7.  Anomalous  subclavian  artery;  the  innominate  absent  (no  carotid). 

8.  Anastomotic  orifice  indicated  by  dotted  lines. 
St.  Sternum. 

The  subclavian  artery  could  not  be  identified  in  the  mass  covering 
the  scalenes,  and  all  efforts  were  centred  upon  securing  control 
of  the  vessel  in  its  first  division.  The  sternomastoid  tendon  at  its 
junction  with  the  sternum,  the  sternohyoid  and  sternothyroid  muscles 
were  freely  divided  at  the  junction  with  the  sternum,  and  were  re- 
tracted with  the  overlying  skin  toward  the  left  side  of  the  neck  by 


252  MAT  AS, 

passing  a  loop  of  silk  thread  through  the  musculocutaneous  flap  thus 
formed. 

The  first  obstacle  encountered  was  in  the  presence  of  the  enlarged 
internal  jugular,  subclavian,  and  innominate  veins,  which,  upon  being 
freed  from  the  confining  restraint  of  the  deep  cervical  aponeurosis 
and  tense  muscles,  immediately  formed  huge  swollen  trunks  which 
completely  crowded  the  field  of  operation. 

Fortunately,  the  disarticulation  of  the  clavicle  and  free  division  of 
the  muscles  of  the  anterior  cervical  region  afforded  a  free  and  easy 
access  to  the  contents  of  the  superior  mediastinum.  Taking  the 
internal  jugular  trunk  as  a  guide,  it  was  followed  to  its  junction  with 
the  subclavian  and  to  the  right  innominate,  which  was  clearly  identi- 
fied. By  carefully  displacing  this  to  one  side  and  the  trachea  on  the 
other,  I  expected  to  find  the  innominate  artery  without  difficulty,  but 
much  to  my  surprise  I  failed  to  find  this  vessel.  Instead  of  this  trunk 
I  found  a  very  large  vessel  which  ascended  upward  into  the  right  side 
of  the  neck  in  the  direction  of  the  subclavian  artery  ;  but  the  com- 
mon carotid  was  absent,  and  for  the  time  being  I  was  perplexed  at 
this  unexpected  state  of  affairs.  In  order  to  satisfy  myself  further,  I 
followed  this  anomalous  vessel  down  into  the  mediastinum,  and  was 
able  to  trace  it  with  the  tip  of  the  finger  to  the  arch  of  the  aorta.  I  then 
made  a  search  for  the  common  carotid  in  the  upper  part  of  the  wound, 
and  was  much  surprised  to  discover  that  this  trunk  was  absent  from  its 
usual  place,  and  evidently  came  from  behind  the  trachea,  and  only 
reached  the  surface  at  a  high  level  near  the  thyroid  gland.  It  was 
evident,  therefore,  that  there  was  no  innominate  artery,  and  that  we 
were  dealing  with  one  of  those  comparatively  rare  anomalies  which 
are  familiar  enough  in  the  dissecting-room,  but  are  extremely  rare 
in  the  history  of  surgical  ligations.  It  took  quite  a  while  before  I 
could  satisfy  myself  that  the  innominate  was  missing  altogether,  as  I 
had  not  anticipated  this  anomaly.  Leaving  anatomical  explanations 
for  future  consideration,  I  proceeded  to  place  a  provisional  silk  loop 
for  traction  on  the  anomalous  subclavian  (Rivington's  plan)  on  a  level 
with  the  sternoclavicular  joint.  When  traction  was  made  upon  this 
loop  the  pulsation  and  thrill  in  the  subclavian  area  and  in  the  veins 
were  arrested. 

It  evidently  controlled  the  circulation  in  the  aneurism  at  that 
time.  When  this  was  ascertained,  the  loop  was  entrusted  to  Dr. 
Gessner. 

By  this  time  (11.55  a.m.)  the  patient,  who  had  been  most  patient 


TRAUMATIC    A  RTE  K  I  O -V  EN  O  US    ANEURISMS.  253 

and  calm,  began  to  show  signs  of  restlessness  and  physical  exhaus- 
tion, and  I  decided  that  the  time  had  come  to  give  him  a  general 
anccsthetic.  Chloroform  was  administered  in  drop  doses,  and  pulse, 
which  had  risen  to  114,  fell  to  100  immediately  after  the  first  inhala- 
tions. The  patient  was  so  tired  physically  and  psychically  from 
prolonged  mental  tension  that  he  inhaled  the  chloroform  greedily.  It 
acted  most  happily  upon  him,  and  soothed  him  without  producing 
absolute  unconsciousness,  which  he  proved  by  replying  intelligently 
to  our  questions,  making  inquiries  as  to  the  progress  of  the  operation. 
He  never  complained  of  the  least  nausea,  and  drank  repeatedly  of 
cold  water,  toddy,  and  even  hot  beef  tea,  whenever  we  stopptd  to 
give  it  to  him.  It  was  only  when  the  serious  hemorrhage  occurred 
in  the  sixth  stage  that  he  became  momentarily  unconscious,  and  it 
was  then,  in  a  large  measure,  due  to  shock  and  exhaustion. 

Sixth  Stage.  Detachment  of  the  subclavian  vein  frotfi  the  artery  at 
the  point  of  injury  after  failure  to  identify  the  third  portion  of  this  vessel 
outside  of  the  sca,lenes  on  accoutit  of  mass  of  exudates  which  masked  it 
completely.  Profuse  hemorrhage  from  the  artery  at  the  anastomotic 
orifice,  in  spite  of  complete  control  of  this  vessel  at  its  origin.  Final 
ligation  of  the  artery  on  each  side  of  the  bleeding-point.  Closure  of 
the  venous  orifice  by  suture  without  obstructing  the  lumen. — This  proved 
to  be  the  only  critical  and  dangerous  stage  of  the  operation.  While 
Dr.  Gessner  controlled  the  subclavian  at  its  origin  I  made  an  effort 
to  dissect  the  artery  out  of  the  mass  of  exudates  in  which  it  was 
embedded  ;  this  was  so  difficult  on  account  of  inextricable  anatomical 
confusion,  caused  by  extravasation  and  exudates,  that  I  decided  to  reach 
the  artery  by  following  the  vein  to  the  anastomotic  orifice.  A  long 
forceps  was  temporarily  placed  upon  the  over-distended  vein  on  the 
proximal  (cardiac)  side  of  the  vein  and  a  careful  dissection  was  begun, 
following  the  axillary  side  of  the  vein  into  the  mass  which  covered  the 
scalenes.  While  doing  this  the  vein  became  suddenly  detached,  and 
instantly  a  flood  of  mixed  arterial  and  venous  blood  deluged  the  field 
and  compelled  immediate  concentration  upon  this  point  to  check  the 
flow  which  for  a  moment  appeared  to  defy  all  efforts  at  local  compres- 
sion with  gauze  pads  and  fingers.  Vigorous  traction  upon  the  loop 
around  the  origin  of  the  subclavian,  held  by  Dr.  Gessner,  did  not 
control  the  bleeding,  which  evidently  came  from  the  vertebral  and 
other  collaterals  into  the  now  severed  anastomosis. 

The  bleeding-point  could  not  be  easily  localized  ;  some  blood  was 
flowing  out  of  the  detached  vein,  but  this  was  easily  controlled  by 


254  MAT  AS, 

forceps ;  the  chief  hemorrhage  came  from  the  opening  in  the  mass  of 
exudates  covering  the  scalene.  By  the  application  of  one  finger,  and 
then  another,  the  bleeding  was  finally  controlled,  but  the  least  relaxa- 
tion of  the  pressure  immediately  allowed  it  to  flow  in  a  gush.  With 
the  finger  on  the  bleeding-point,  reinforced  by  the  additional  finger 
of  one  of  the  assistants  (Dr.  Maes),  I  made  a  vertical  incision  into 
the  mass  by  the  side  of  the  finger,  and  succeeded  in  bringing  to  view 
the  aponeurotic  edge  of  the  scalenus  anticus,  which  I  detached  almost 
completely  from  its  insertion  by  cutting  into  it  from  the  axillary  side 
on  a  level  with  the  tubercle  ;  the  muscle  was  not  entirely  detached  at 
its  insertion  for  fear  of  injuring  the  phrenic  nerve,  but  the  section  was 
sufficient  to  allow  me  to  insinuate  the  right  index  into  the  inter- 
scalenal  space,  where  I  recognized  a  firm,  flat  cord,  which  I  took  to  be 
the  third  portion  of  the  subclavian  artery.  The  vessel  was  now  seized 
with  a  longbladed  clamp.  I  then  cautiously  removed  my  left  index 
from  the  bleeding-point  on  the  scalene,  and  had  Dr.  Maes  substitute 
his  fingers  for  mine  over  the  orifice,  which  he  did  so  quickly  that  no 
blood  was  lost  in  the  exchange.  I  was  then  able  to  trace  the  sub- 
clavian artery  from  the  point  where  it  had  been  grasped  by  the  forceps 
to  the  posterior  surface  of  the  scalene.  The  artery  was  found  adherent 
to  the  posterior  surface  of  the  muscle,  the  bullet  having  perforated  it 
in  its  central  portion.  The  muscle  was  interposed  like  a  diaphragm 
between  the  artery  and  the  vein,  leaving  only  a  small  opening, 
scarcely  long  enough  to  admit  an  ordinary  lead-pencil  through  it.  By 
retracting  and  pulling  on  the  outer  border  of  the  partially  divided 
scalene,  the  posterior  surface  of  the  muscle  could  be  brought  to  view, 
and  the  continuity  of  the  injured  artery  could  be  established  on  the 
proximal  (cardiac)  side  of  the  vessel.  Another  long,  narrow  bladed 
forceps  was  now  placed  upon  the  vessel  just  beyond  the  point  of  adhe- 
sion to  the  muscle,  thus  occluding  the  lumen  of  the  vessel  on  the 
cardiac  side  of  the  perforation.  When  this  was  done,  digital  com- 
pression had  been  stopped,  and  we  had  the  satisfaction  of  seeing  that  all 
bleeding  was  arrested.  A  fine  kangaroo  tendon  ligature  (Van  Horn) 
was  now  applied  to  the  subclavian  artery  outside  of  the  scalene,  and 
another  (of  the  same  material)  to  this  vessel  on  the  inner  side  of  the 
perforation,  which  had  apparently  involved  three-fourths  of  the  cir- 
cumference of  the  artery.  The  artery  was  then  divided  completely 
at  the  injured  point.  Fearing  that  the  proximal  side  of  the  artery 
had  not  been  sufficiently  secured,  and  that  the  ligature  might  slip 
because  it  was  too  close  to  the  divided  edge,  another  ligature  was  placed 


TRAUMATIC    A  RT  ER  I  O-V  ENO  US    ANEURISMS.  255 

almost  half  an  inch  beyond  the  first  on  the  inner  side  of  the  scalenus 
muscle.  In  order  to  do  this  effectively  the  divided  or  free  end  of 
the  artery  was  seized  with  long-bladed  forceps,  and  was  forced  to  the 
surface  through  the  mass  of  exudates  which  still  covered  and  filled  the 
right  prevertebral  space.  The  ligated  stump  then  appeared  on  the 
inner  edge  of  the  muscle,  where  it  was  pulled  out  and  twisted  upon 
itself,  and  then  ligated,  as  previously  stated,  about  three-fourths  of  an 
inch  from  the  terminal  ligature.  This  ligature  must  have  been  placed 
very  close  to  the  origin  of  the  thyroid  axis  and  internal  mammary, 
and  the  axial  rotation,  to  which  the  main  trunk  was  subjected,  must 
have  had  some  effect  in  occluding  the  origin  of  these  vessels.  It  is 
possible,  also,  that  by  adopting  this  radical  procedure  much  inter- 
ference was  caused  with  the  collateral  supply  furnished  by  these  im- 
portant branches,  as  I  can  account  in  no  other  way  for  the  sloughing 
of  the  hand  and  arm  which  followed.  I  was,  however,  so  profoundly 
impressed  at  the  time  with  the  enormous  force  of  the  collateral  circu- 
lation through  the  vertebral  and  internal  mammary  that  I  would  take 
no  chances  of  secondary  hemorrhage  by  leaving  a  single  ligature  at 
the  terminal  and  injured  part  of  the  artery.  In  fact,  I  would  have 
ligated  the  vertebral  if  the  condition  of  the  patient  would  have  per- 
mitted of  longer  delay.  After  these  ligatures  had  been  applied  and 
the  vessel  thoroughly  secured,  the  traction  loop  on  the  mediastinal 
portion  of  the  subclavian  was  removed. 

The  subclavian  vein,  which  had  now  been  detached  from  the  mass 
of  exudates  which  bound  it  to  the  anterior  scalene  and  the  arterial 
opening  of  communication,  was  carefully  examined.  It  was  found  to 
be  circular  and  to  involve  only  a  part  of  the  lumen  of  the  vessel. 
We,  therefore,  proceded  to  suture  this  orifice,  and  closed  it  completely 
without  occluding  the  lumen  of  the  vein.  After  this  had  been  done 
the  clamp  and  provisional  ligature  placed  on  each  side  of  the  sutured 
point  were  removed,  and  it  was  noticed  that  the  circulation  in  the  vein 
was  restored,  though  the  calibre  of  the  vessel  was  very  much  reduced 
in  size,  the  return  flow  from  the  axillary  side  being  very  small  on  ac- 
count of  the  great  diminution  in  the  arterial  supply  of  the  arm.  The 
subclavian  and  jugular  veins,  which  previously  had  been  enormously 
distended,  now  became  very  flat  and  much  reduced  in  size,  and  pre- 
sented a  very  marked  contrast  to  the  conditions  existing  prior  to  the 
ligation  of  the  artery. 

The  patient's  condition  had,  in  the  meantime,  undergone  serious 
and  unfavorable  changes  during  these  long,  tedious,  and  exhausting 


256  MATAS, 

manipulations.  The  pulse  at  11. 16  was  100;  at  12,  it  was  120;  and 
at  12.20,  when  the  first  great  gush  of  blood  followed  the  detachment 
of  the  vein,  it  rose  immediately  to  140.  The  quality  of  the  pulse, 
which  had  been  remarkably  good  before,  now  showed  the  marked 
effects  of  shock,  though  it  remained  fairly  good.  Nevertheless,  we 
decided  to  infuse  with  saline  solution,  and  four  and  a  half  pints  of  hot 
salt  solution  (0.7  of  i  per  cent.)  were  injected  through  the  m.edian 
basilic,  which  had  been  exposed  and  held  in  readiness  for  the  purpose. 
This  brought  down  the  pulse  to  108 ;  but  it  again  grew  weak,  and 
at  2  p.  M.  was  140  again.  In  the  meantime  the  patient,  who  was  very 
pale  and  covered  with  a  profuse  cold  sweat,  was  made  to  drink  freely 
of  toddy  and  given  hypodermics  of  strychnine  and  digitaline,  with 
i/ioo  gr.  of  atropia  sulph. 

Seventh  Stage.  Readjustment  of  flap  ;  closure  of  wound ;  drainage. — 
While  these  restorative  measures  were  being  vigorously  applied  we 
attempted  to  replace  the  clavicle  with  the  osteoplastic  flap  (skin, 
aponeurosis,  sternomastoid)  into  position,  but  found  that  by  so  doing 
it  would  be  difficult  to  obtain  a  complete  apposition  of  the  soft  parts 
above  the  clavicle,  and  thus  leave  dead  spaces.  I  therefore  decided 
to  sacrifice  the  bone  for  the  sake  of  obliterating  all  dead  spaces,  and 
removed  it  entirely  from  the  musculocutaneous  flap,  to  which  it  was 
firmly  attached  by  its  periosteal  covering.  An  iodoform  gauze  drain 
was  left  in  the  anterior  mediastinum,  and  the  flap  was  sutured  into 
place  by  a  series  of  interrupted  silkworm  sutures. 

Eighth  Stage.  The  bullet  was  extracted  by  an  incision  over  the 
anterior  edge  of  the  trapezius,  and  found  to  be  a  38  calibre  and  ab- 
solutely undeformed.  It  had  not  even  grazed  the  clavicle,  as  I  at  first 
suspected,  and  had  passed  upward  under  the  bone  without  touching 
it.  This  remarkable  fact  could  only  be  accounted  for  by  the  eleva- 
tion of  the  arm  when  the  patient  was  shot,  and  while  he  was  holding 
his  antagonist  to  the  ground. 

A  large,  firm,  dry  gauze  compress  was  now  applied  over  the  field  of 
the  operation,  reinforced  with  an  absorbent  cotton  pad,  all  being  held 
by  a  long  spica,  which  equally  compressed  the  wounded  surfaces.  In 
addition,  large  broad  strips  of  adhesive  plaster  were  applied  over  the 
bandage  and  over  the  shoulder,  from  the  scapular  region  to  the  chest, 
thus  giving  additional  security  to  the  bandage.  The  arm,  which  was 
quite  cold  on  the  affected  side,  was  now  wrapped  up  in  cotton  batting 
from  the  fingers  to  the  axilla,  the  cotton  being  held  in  place  by  a 
loose  spiral-roller  bandage. 


TRAUMATIC    A  RT  ER  I  O-VENO  US    ANEURISMS.  25/ 

The  patient  was  perfectly  conscious,  but  completely  exhausted  and 
shocked.  He  was  extremely  pale,  the  pupils  moderately  dilated,  and 
the  pulse  small,  and  for  a  few  moments  after  he  had  been  transferred 
to  the  rolling  carriage  it  was  very  small  and  scarcely  perceptible  at  the 
wrist.  He  complained  of  chilly  sensations  and  shivered.  After  warm- 
ing him  with  hot  bags  and  blankets  he  was  (at  2.45  p.m.)  taken  to  his 
bed,  when  he  was  given  a  toddy  and  copious  draughts  of  ice  water,  which 
he  craved  incessantly,  and  which  fortunately  he  never  rejected.  At 
3.45  P.M.  he  was  still  extremely  weak,  almost  collapsed;  he  felt  cold 
on  the  surface,  but  the  thermometer  in  the  rectum  showed  a  tempera- 
ture of  1031°,  At  4.50  P.M.  the  rectal  temperature  was  104°,  and 
half  an  hour  later  104^°.  At  10  p.m.  his  pulse,  which  at  one  time 
had  risen  to  150,  had  fallen  to  100,  beating  regularly,  full,  and  strong  ; 
his  temperature  had  fallen  to  loif,  and  he  was  resting  quietly,  but 
perspiring  profusely  as  defervescence  progressed. 

History  Subsequent  to  Operation.  The  subsequent  career  of  this 
patient  after  the  operation  was  marked  by  many  incidents  which  de- 
layed his  convalescence  and  caused  us  much  anxiety  as  to  the  ultimate 
fate  of  his  arm,  but  never  gave  us  serious  apprehensions  as  to  his  ulti- 
mate recovery. 

Some  idea  may  be  obtained  of  the  tediousness  of  his  convalescence 
by  noting  that  he  was  admitted  to  the  hospital  on  September  8th 
(fifth  day  after  the  injury),  was  operated  on  September  13th  (ninth 
day),  and  was  discharged  November  12,  1900  (sixty-first  day),  and 
even  then  his  arm  had  not  healed,  and  he  was  not  entirely  discharged 
by  Dr.  Power  at  his  home  until  April  19,  1901  (158  days  after  leaving 
the  sanitarium),  when  he  discarded  his  last  dressings.  He  was,  there- 
fore, under  treatment  a  little  over  seven  months  from  the  date  of  the 
operation.  It  is  just  to  state  that  this  delay  in  his  complete  recovery 
was  caused  almost  entirely  by  the  sloughing  which  took  place  in  the 
hand  and  forearm,  which  followed  immediately  after  the  ligature  of  the 
artery.  The  wound  in  the  neck  healed /<?r/r/waw,  and  never  gave  us 
the  least  anxiety.  With  the  exception  of  a  stitch  abscess  it  healed  with- 
out interruption  and  was  entirely  well  on  the  twenty-second  day,  when 
all  dressings  were  discontinued  in  the  neck.  The  necrotic  changes  that 
took  place  in  the  hand  and  forearm  are  of  such  rare  occurrence  after 
ligations  of  the  subclavian  vessels  that  they  deserve  special  reference 
in  this  history.     My  notes  in  reference  to  this  point  read  as  follows  : 

"September  14th.     Friday,  9  a.m.  (the  day  after  the  operation), 

patient's  general  condition  much  improved.     Pulse,   no;  tempera- 
Am  surg  17 


258  MATAS, 

ture,  99^°.  Patient  complains  of  little  pain  in  region  of  wound, 
which,  in  addition  to  copious  aseptic  dressings  and  spica  bandage,  has 
been  covered  with  a  square  flat  bag  filled  with  bird  shot,  weighing 
half  a  pound,  to  further  compress  the  part  and  favor  the  obliteration 
of  dead  spaces. 

"  The  cotton  batting  and  loose  bandage  are  removed  from  the  arm, 
and  I  am  painfully  surprised  to  find  evidences  of  complete  mortifica- 
tion of  several  digits  and  parts  of  the  palm  of  the  hand  and  forearm; 
the  skin  in  some  places  on  the  ulnar  side  appears  to  be  necrotic  up  to 
the  elbow.  Complete  insensibility  of  the  entire  extremity  up  to  the 
bend  of  the  elbow  exists.  After  washing  the  extremity  in  hot  water 
and  alcohol,  the  capillary  circulation  is  found  to  exist  in  considerable 
areas  over  the  dorsum  of  the  hand,  wrist,  and  forearm ;  but  the  palm 
and  fingers,  especially  the  little  finger  and  the  thumb,  appear  to  be 
hopelessly  lost.  No  radial,  brachial,  or  axillary  pulse  can  be  felt. 
The  arm  down  to  the  elbow  is  sound,  warm,  and  sensitive.  The  hand 
is  shrivelled,  pale,  waxy,  cadaveric ;  here  and  there  a  few  patches  of 
capillary  extravasation  or  stains ;  no  swelling,  oedema  or  violaceous 
discoloration  ;  no  signs  of  venous  asphyxia ;  the  superficial  veins, 
which  before  the  operation  were  prominent  and  turgid,  had  now  be- 
come invisible.  The  mortification  is  evidently  due  to  arterial  ischaemia. 
Arm  wrapped  up  loosely  in  cotton  batting  and  surrounded  with  hot 
bags." 

At  3  P.M.  the  temperature  had  risen  to  101°  ;  pulse,  136.  Evidently 
the  reactionary  changes  due  to  the  sloughing  were  causing  the  disturb- 
ance, because  there  was  nothing  in  the  wound  to  account  for  the 
change.  At  4.30  p.m.,  pulse  130;  at  7.30,  pulse  128,  temperature 
101°,  skin  moist,  general  condition  excellent.  The  hand,  at  wrist 
and  forearm,  is  now  beginning  to  show  oedema,  and  there  are  dry 
patches  of  dark  extravasation  over  the  mortified  areas.  The  arm 
above  the  wrist  and  elbow  and  in  proximity  to  the  dead  parts  is  hot 
and  presents  a  dusky  red  erythematous  color. 

On  September  20th  the  following  observations  are  recorded  :  "  The 
affected  arm  is  still  much  swollen  and  oedematous,  though  the  swelling 
is  now  subsiding.  The  thumb-nail  and  skin  in  palmar  and  dorsal 
aspects  of  the  thumb  mummified,  shrivelled,  dry,  purplish-black  in 
color;  tip  of  index  finger  and  nail,  black  and  dry  ;  ring  finger  to  first 
knuckle  black ;  two  large  black,  dry  patches  in  palm  of  hand  and 
base  of  thumb ;  another  large  black,  leathery  patch  over  the  entire 
hypothenar  region.     A  large  blister  was  formed  extending  over  the 


TRAUMATIC    A  RTE  R  I  O -VENO  US    ANEURISMS.  259 

ulnar  and  dorsal  aspects  of  the  forearm.  The  arm  was  treated  by 
daily  washing  with  hot  lysol  solution  (i  per  cent.),  followed  by  com- 
plete alcohol  bath,  after  which  it  was  thickly  covered  with  an  oint- 
ment consisting  of  ichthyol  and  zinc  oxide  and  vaseline  ;  over  the  fore- 
arm and  arm,  where  the  skin  appeared  to  be  red  and  inflamed,  com- 
presses of  dilute  lead  and  opium  lotion  were  kept  constantly  applied. 

On  September  aSth  I  left  the  city  for  a  month's  vacation  and  trans- 
ferred the  patient  to  Dr.  Gessner,  who  continued  to  attend  and  dress 
him  carefully  until  my  return,  October  31st,  when  the  following  obser- 
vations were  noted  :  "  General  condition  excellent ;  temperature  and 
pulse  normal ;  good  appetite ;  patient  sits  up.  Wound  in  the  neck 
completely  healed  since  September  20th,  requiring  no  dressing.  The 
most  important  changes  have  taken  place  in  the  hand  and  forearm. 
The  little  finger  had  dropped  off,  leaving  a  large  granulating  surface 
in  the  hypothenar  region  ;  a  large  granulating  surface  over  the  thenar 
eminence,  where  the  skin  had  also  sloughed  off.  The  thumb  had 
sloughed  and  had  to  be  excised.  The  first  metacarpal  is  exposed  on 
the  palmar  side.  A  deep  palmar  tunnel  connects  the  granulating 
surfaces  on  the  two  sides  of  the  hand.  This  tunnel  in  the  palm  is 
caused  by  the  sloughing  of  the  long  flexor  tendons  and  some  of 
the  interossei.  The  ulna  from  its  upper  third  down  to  the  wrist- 
joint  is  exposed,  even  the  periosteum  being  lost.  Only  the  styloid 
process  and  articular  end  are  sound  and  covered  with  soft  parts.  All 
the  pronato-flexor  mass  of  muscles  and  other  soft  parts  covering 
the  ulna  have  sloughed  off,  leaving  a  granulating  tissue  on  the  peri- 
osteum, apparently  trying  to  cover  it,  A  long  sinus,  caused  by  the 
sloughing  of  the  supinator  and  extensor  muscles  and  brachialis  anticus, 
can  be  traced  upward  into  the  lower  third  of  the  arm.  Four  and  a  half 
inches  of  necrotic  ulna  were  excised  with  the  Gigli  saw ;  the  first 
metacarpal  was  enucleated  out  of  its  periosteal  shell.  The  nail  and 
terminal  phalanx  of  the  index  were  removed ;  the  gaps  in  the 
palmar  side  were  covered  over  with  dorsal  cutaneous  flaps.  A  free 
incision  was  made  from  the  forearm  to  the  arm  into  the  external  inter- 
muscular septum  to  remove  the  sloughs  formed  by  the  supinator  and 
the  brachialis  anticus  ;  the  musculospinal  and  ulnar  nerves  have  been 
lost  in  the  deep  sloughing  of  the  forearm ;  there  is  complete  anaes- 
thesia of  all  parts  below  the  elbow." 

After  this  the  condition  of  the  arm  steadily  improved,  and  the  patient 
was  discharged  November  12th  in  verygood  general  condition,  but  still 
suppurating  through  several  granulating  sinuses.     After  this  his  arm 


26o  MAT  AS, 

was  attended  to  at  his  home  by  Dr.  Power,  who  had  to  open  another 
sinus  resulting  from  extension  of  suppuration  in  the  arm.  He  also 
wrote  that  the  wound  in  the  neck  had  reopened  at  one  point  for  a  few 
days,  but  had  healed  without  discharging  any  ligatures. 

Finally,  when  the  patient  came  to  see  me,  April  19th,  his  arm  was 
entirely  healed  and  presented  the  appearance  shown  in  the  photo- 
graph. He  had  lost  his  thumb  and  little  finger,  and  the  remaining 
digits  were  living,  but  stiff,  rigid,  and  completely  anaesthetic.  He 
has  a  stiff  wrist  and  a  much  reduced  forearm,  the  ulna  being  wanting. 
Nevertheless,  he  has  slight  supination  and  pronation,  caused  by  preser- 
vation of  the  biceps  tendon,  and  has  fairly  good  motion  at  the  elbow. 
The  skin  is  devoid  of  sensation  up  to  the  elbow. 

In  closing  the  description  of  the  case  we  would  call  attention  to 
the  following  points: 

1.  That  the  lesion  caused  by  the  bullet  was  a  true  aneurismal 
varix  of  the  middle  third  of  the  subclavian  artery  and  vein  just 
where  the  vessels  are  separated  by  the  musculo-aponeurotic 
partition  formed  by  the  scalenus  anticus. 

2.  That  a  continuous  direct  channel  had  formed  between  the 
artery  and  vein  through  the  small  perforation  in  the  muscle. 

3.  The  early  establishment  of  a  communication  between  the 
artery  and  the  vein  was  favored  in  this  case  by  the  primary 
hemorrhage,  which  immediately  filled  up  the  rigid  and  unyield- 
ing space  between  the  scalenes  and  forced  the  artery  against  the 
posterior  surface  of  the  muscle,  thus  compelling  the  stream  of 
blood  to  escape  through  the  small  perforation  made  by  the  bul- 
let, and  directing  it  in  the  line  of  least  resistance — i.e.,  toward 
the  opening  in  the  vein,  which  was  held  against  the  anterior 
surface  of  the  muscle  by  the  clot  which  accumulated  in  the 
space  bounded  by  the  scalene,  clavicle,  and  deep  cervical 
fascia. 

4.  That  the  stream  of  arterial  blood  in  the  subclavian  artery 
had  been  almost  completely  short-circuited  and  was  poured  into 
the  proximal  or  cardiac  side  of  the  subclavian  vein,  which  was 
enormously  distended  thereby,  the  circulation  of  the  upper 
extremity  being  kept  up  chiefly  by  the  collateral  circulation. 

5.  That  a  simultaneous  contusion  and  injury  of  the  brachial 


TRAUMATIC    ARTEKIO -VENOUS    ANEURISMS.  26 1 

plexus  existed,  which  led  to  a  paralysis  of  sensation  and  motion, 
which  was  intensified  by  arterial  ischaimia  of  the  arm. 

6.  That  the  dissection  and  elevation  of  an  osteoplastic  flap, 
including  the  inner  two-thirds  of  the  clavicle,  was  most  advan- 
tageous in  securing  a  free  access  to  the  injured  parts. 

7.  That  the  innominate  artery  was  missing,  and  in  its  place  an 
anomalous  subclavian,  originating  from  the  arch  of  the  aorta, 
existed  ;  the  corresponding  common  carotid,  originating  in  the 
arch  on  the  left  side  of  the  trachea,  did  not  reach  the  surface 
until  it  had  ascended  to  the  lower  level  of  the  thyroid  gland. 

8.  That  the  provisional  loop  of  silk  applied  around  the 
origin  of  the  subclavian  to  secure  prophylactic  hemostasis  in 
the  field  of  operation  failed  to  control  the  bleeding  from  the 
proximal  side  of  the  arterio-venous  orifice  when  the  vein  was 
detached. 

9.  That  bleeding  from  the  subclavain  at'  the  aneurismal  orifice 
was  only  controlled  after  the  artery  had  been  secured  by  a 
double  ligature  applied  on  each  side  of  the  bleeding-point — i.e., 
on  the  inner  and  outer  side  of  the  anterior  scalene. 

10.  That  in  future  operations  in  similar  conditions  the  only 
means  of  securing  absolute  prophylactic  hemostasis  (on  the  arte- 
rial side)  would  be  to  resort  to  digital  compression  over  the 
subclavian  artery  at  the  origin  of  the  vertebral  (just  below  the 
tubercle  of  the  fifth  cervical  vertebra)  in  addition  to  the  trac- 
tion loop  of  silk  applied  around  the  innominate.  The  applica- 
tion of  a  traction  loop  on  the  first  portion  of  the  subclavian  on  the 
outer  (axillary)  side  of  the  origin  of  the  vertebral  is  a  procedure 
beset  with  many  difficulties,  because  of  the  numerous  enlarged  and 
adherent  veins  which  are  matted  together  in  a  mass  of  exudates 
and  which  would  flood  the  field  at  the  least  provocation.  Digital 
compression  of  the  vertebral  could  be  readily  and  effectively 
applied,  while  the  innominate,  which  as  a  rule  is  quite  accessible, 
would  be  compressed  by  the  traction  loop. 

11.  That  it  is  possible,  as  shown  by  this  case,  to  restore  the 
continuity  of  the  subclavian  vein  by  lateral  suture  after  detaching 
it  from  the  aneurismal  orifice. 

12.  That  the   possibility  of  mortification   of  the  peripheral 


2^2  MATAS, 

part  of  the  extremity  must  not  be  overlooked   in   considering 
the  prognosis  and  post-operative  results. 

13.  That  this  ischaemic  necrosis  of  the  extremities  is  more 
liable  to  occur  when  the  subclavian  is  subjected  to  torsion  in  its 
second  division,  thus  probably  obliterating  or  injuring  the  orifices 
of  the  thyroid  axis,  vertebral  and  other  branches. 

14.  That  the  partial  mortification  of  the  hand  and  forearm  in 
this  case,  while  traceable  directly  to  the  arterial  ischaemia,  was 
probably  favored  by  the  defective  innervation  of  the  parts  from 
injury  to  the  brachial  plexus. 

15.  That  a  notable  feature  of  the  sphacelation  was  that  it 
especially  involved  large  muscular  groups  rather  than  the  over- 
lying skin,  thus  confirming  the  observations  of  Lesser,  Volk- 
mann,  Ludwig,  Bernays  and  others  on  the  degenerating  and 
necrobiotic  effect  of  arterial  ischgemia  upon  muscular  tissue. 

16.  That  the  advantages  of  massive  infiltration  with  very 
dilute  eucain  and  cocain  solutions  were  well  shown  in  this  case, 
as  they  economized  the  use  of  the  general  anaesthetic  and  per- 
mitted not  only  the  painless  resection  of  the  clavicle,  but  also 
facilitated  the  exploration  of  the  deep  cervical  bloodvessels 
while  applying  a  traction  loop  of  silk  around  the  anomalous 
subclavian  at  its  origin. 

17.  That  when  a  general  anaesthetic  becomes  necessary, 
chloroform,  preceded  by  morphine,  is,  in  these  cases,  better  than 
ether,  because  it  is  not  accompanied  by  as  much  respiratory 
disturbance  and  overdistention  of  the  veins. 

18.  That  the  experience  of  the  author  in  this  case  confirms 
his  previous  observations  and  those  of  others  (Gushing,  LiH- 
enthal,  Jaboulay,  etc.)  to  the  effect  that  the  preliminary  admin- 
istration of  morphine,  followed  by  local  infiltration,  apparently 
predisposes  to  the  favorable  and  economical  administration  of 
chloroform,  which,  in  this  case,  was  never  pushed  to  absolute 
unconsciousness. 

Historical  Data. 

The  history  of  arterio-venous  aneurism  clinically  begins  with 
the  first  accurately  recorded  case,  described  by  William  Hunter 


TRAUMATIC    ARTERIO -VENOUS    ANEURISMS.  263 

in  1757,  and  anatomically  by  the  description  of  Delacombe  in 
1761,  which  was  based  on  the  post-mortem  study  of  a  lesion  im- 
plicating the  femoral  vessels  (Broca).  The  first  accurate  account 
of  arterio-venous  aneurism  of  the  subclavian  vessels  dates  back 
to  the  classical  case  of  the  Sargent  Pierre  Cadrieux,  whose  in- 
jury was  treated  by  the  distinguished  Dominique  J.  Larrey  in 
1829.  and  made  memorable  by  his  admirable  description  of  this 
condition  in  his  Cliniqiies  Chirurgicales,  Paris,  1829,  vol.  iii.  p. 
115. 

From  1829  to  the  present  time  we  have  been  able  to  gather 
the  records  of  15  cases  of  arterio-venous  aneurism,  including 
our  present  observation.  The  recorded  traumatisms  of  the  sub- 
clavian vessels  are  rare,  not  only  because  these  vessels  are  well 
protected  by  the  clavicle,  and  are  not  so  much  exposed  to  injury 
as  those  of  the  extremities,  but  chiefly  because  accidental  injury 
to  these  vessels  is  so  liable  to  a  promptly  fatal  termination 
from  associated  complications,  and  the  profuse  primary  hem- 
orrhage and  shock,  that  the  patients  do  not  survive  long 
enough  to  be  subjected  to  any  form  of  surgical  treatment. 
Nevertheless,  in  1877,  Von  Bergmann  was  able  to  collect  90 
recorded  instances  of  injury  (gunshot  and  stab)  of  the  subcla- 
vian vessels.  Rotter,  of  Berlin,  as  near  to  us  as  1893,  was  able 
to  collect  only  14  cases  of  stab  wounds  of  the  subclavian  ves- 
sels ;  and  Souchon,  in  his  remarkable  essay  on  the  surgery  of 
the  subclavian  artery,  published  in  1895,  was  able  to  collect  only 
14  cases  of  arterial  traumatic  aneurisms,  all  involving  the  third 
division  of  the  right  subclavian. 

Our  collection  of  15  cases  of  arterio-venous  aneurisms,  gath- 
ered from  all  sources  in  the  literature,  are  all  traumatic,  and  in- 
clude injuries  to  the  vessels  on  either  side,  irrespective  of  the 
topographical  division  of  the  artery  involved,  though,  in  a  large 
majority  of  these,  the  precise  point  of  injury  could  not  be  ac- 
curately ascertained. 

The  cases  are  reported  in  chronological  order  by  the  follow- 
ing observers:  (i)  Larrey  (D.  J.),  Paris,  1829;  (2)  Sanson,  quoted 
by  Robert,  Paris,  1832;  (3)  Berard,  quoted  by  Richet,  Paris, 
1842;    (4)  Wattmann,  Vienna,    1843;   (5)  Wederstrandt,  New 


264  MATAS, 

Orleans,  1854;  (6)  R.  W.  Smith,  Dublin,  i860;  (7)  Fischer, 
Gottingen,  1861  ;  (8)  Letenneur,  Nantes,  1861 ;  (9)  Will  (J.  C. 
Ogilvie),  Glasgow,  1875;  (10)  Kirsch  (B.),  Breslau,  1875;  (il) 
Arango  (A.  P.),  Medellin,  Spain,  1880;  (12)  Rotter  (J.  V.), 
Berlin,  1893;  (13)  Wedekind  (G.),  Berlin,  1893;  (14)  Veiel, 
Cannstadt ;  (15)  Matas,  New  Orleans,  1900.' 

The  reports  of  these  cases,  together  with  the  comments  of 
the  authors  and  the  important  discussions  which  followed  the 
presentation  of  several  of  these  to  various  medical  societies,  fur- 
nish the  available  data  upon  which  the  special  history  of  this 
rare,  interesting,  and  serious  lesion  is  based. 

Analysis  of  Cases. 

An  analysis  of  these  15  cases  furnishes  the  following  points 
of  interest : 

{a)  Nine  were  caused  by  stab  or  penetrating  cut  wounds  ;  6 
by  bullets. 

{b)  All  the  patients  were  men. 

{c)  The  injuries  were  almost  all  inflicted  upon  comparatively 
young  subjects.  Of  the  9,  whose  ages  are  distinctly  specified, 
the  oldest  was  thirty-two  years  of  age  at  time  of  the  injury;  the 
youngest  fifteen  years.  In  six  cases  the  ages  are  not  specifically 
stated,  but  the  evidence  would  point  to  the  fact  that  none  had 
exceeded  the  middle  period  of  life. 

(d)  In  6  cases  the  vessels  on  the  left  side  were  injured;  in  7, 
those  on  the  right;   in  2,  the  side  injured  is  not  stated. 

{/)  The  seat  of  injury  was  absolutely  demonstrated  to  be  in 
the  subclavian  vessels  in  7  (Wattmann's,  Wederstrandt's,  Will's 
Rotter's,  Wedekind's,  Veiel's,  Matas'),  either  by  autopsy  or 
operation. 

(/)  In  all  the  cases  but  2,  in  which  the  seat  of  the  lesion  is 
either  positively  or  approximately  stated,  the  third  division  out- 
side the  scalenus  was  implicated.     In   Letenneur's   case  injury 

1  To  these  fifteen  cases  two  more  should  be  added,  viz.,  Reboul's,  Montpellier,  1894, 
fatal,  not  operated;  Vallas',  Lyons,  1900,  fatal,  operated:  both  caused  by  indirect  frac- 
ture of  the  clavicle;   in  all,  seventeen  cases. 


TRAUMATIC     ARTERIO -VENOUS     ANEURISMS.  265 

of  the  first  division  was  suspected.  In  the  author's,  the  second 
division  was  positively  involved. 

In  the  8  other  cases  the  diagnosis  of  injury  of  the  subclavian 
vessels  was  confirmed  by  the  seat  of  the  external  lesion,  course 
of  weapon,  and  range  of  the  missile,  the  tumor,  the  immediate 
effect  upon  the  circulation  of  the  arm,  and  the  other  physical  signs, 
showing  that  the  subclavian  trunks,  and  not  their  branches,  had 
been  injured. 

In  5  of  the  15  cases  the  brachial  plexus  was  coincidently 
and  partially  injured;  positively  in  3  (Larrey's,  Wederstrandt's, 
Matas);  probably  in  Letenneur's  and  Kirsch's  cases.  In  several 
cases,  in  which  reference  to  the  condition  of  the  arm  is  made,  the 
disability  of  the  arm  was  pronounced,  but  was  either  due  to  pri- 
mary or  secondary  vascular  disturbances  (Wattmann  (secondary), 
Smith,  Arango,  Wedekind,  Veiel). 

Primary  circulatory  or  neural  disturbances  may  have  existed 
in  other  cases,  but  this  cannot  be  stated  from  the  published 
reports. 

The  //wz^  after  the  injury,  when  the  first  sign  of  arterio-venous 
aneurism  was  first  recognized,  is  stated  in  8  out  of  the  11  un- 
operated  cases  ;  in  3  it  is  only  approximated  ;  in  i  the  charac- 
teristic thrill  and  murmur  were  apparently  altogether  missing 
(Will's  case);  in  3  no  information  on  this  point  can  be  obtained. 
In  I  (Matas')  the  signs  of  arterio-venous  communication  were 
established  within  four  hours  after  the  injury;  in  3  cases  they 
were  present  on  the  second  day  (Larrey,  Wederstrandt  (?),  Rot- 
ter) ;  in  3  the  diagnosis  was  made  on  the  third  day  (Letenneur, 
Kirsch  (?),  Wedekind  ;  in  i  on  the  sixth  day  (Fischer  (?) ) ;  in 
I  on  the  eighth  day  (Arango);  in  i  on  the  ninth  day  (Veiel); 
in  I  "a  few  days  later,"  after  the  injury  (Berard's  case).  Apart 
from  injury  to  the  brachial  plexus  and  purely  vascular  disturb- 
ances in  the  arms  complications  are  noted  in  Wattmann's  case 
(secondary  phlegmonous  inflammations  of  arm) ;  in  Will's  (septic 
hemopyothorax) ;  in  Wedekind's  (septic  phlebitis  and  pneu- 
monia). In  only  3  of  the  15  cases  did  secondary  hemorrhage 
follow  after  the  primary  injury,  and  these  were  all  stab  wounds 
(Will,  R6tter,  Veiel). 


266  MATAS, 

Results  in   Unoperated  Cases. 

Of  the  15  cases  11  were  treated  expectantly,  and  of  these  i 
died  from  secondary  hemorrhage  and  septic  comphcations  three 
weeks  after  the  injury,  and  after  the  external  wound  had  healed 
(Will's  case).  The  remaining  10  all  survived  the  immediate 
effects  of  the  injury,  their  wounds  healing  after  the  cessation 
of  the  primary  hemorrhage. 

Only  4  out  of  the  15  cases  were  operated  upon;  in  3  of 
these  (Rotter,  Veiel,  Matas)  within  twelve  days  after  the  in- 
jury, and  all  recovered ;  in  i  (Wattmann's  case)  thirty-two 
years  after  the  primary  injury,  when  the  ligation  of  the  sub- 
clavian was  necessitated  by  urgent  aneurismal  complications, 
and  this  was  the  only  fatal  case.  The  total  mortality  of  the 
entire  group  is,  therefore,  2  :  15,  or  13^  per  cent/ 

An  investigation  of  the  individual  records  as  far  as  they  are 
available  shows  the  following  results  as  regards  the  final  out- 
come of  this  injury  on  the  vessels  and  upon  the  affected  arm  : 

1.  In  Larrey's  case  (sabre  cut)  four  years  after  the  injury  there 
was  marked  diminution  in  the  aneurismal  signs,  but  the  arm 
was  disabled  completely  by  paralysis,  contracture  of  fingers 
and  hand,  the  pulse  in  the  brachial  and  radial  vessels  sup- 
pressed, and  the  circulation  in  the  superficial  veins  obliterated. 

2.  Sanson's  patient  (gunshot),  quoted  by  Robert,  was  living 
ten  or  more  years  after  the  injury,  but  still  annoyed  by  a  loud, 
purring  murmur  (ronflement)  and  other  active  signs  of  aneu- 
rism, which  could  be  heard  at  a  distance,  and  for  which  he 
consulted  Sanson. 

3.  Berard's  case,  quoted  by  Richet  (stab),  left  the  hospital 
"  several  weeks  "  after  the  wound  had  healed,  but  complaining 
of  the  annoyance  caused  by  the  disturbing  noises  in  the  aneu- 
rism. These  seemed  to  exasperate  him,  and  he  clamored  for  an 
operation,  which  neither  Berard  nor  Dieffenbach  would  perform. 

4.  Letenneur's  patient  (small  pistol  shot)  healed,  with  persist- 
ence of  all  the  aneurismal  signs,  but  felt  well  and  was  able  to 

1  If  we  add  the  two  fatal  cases  of  Reboul  and  Vallas  the  mortality  is  increased  4 :  17, 
or  23^"-  per  cent. 


TRAUMATIC    A  RT  E  R  I  0-VENOUS    ANEURISMS.  267 

take  his  first  promenade  twenty-one  days  after  the  injury,  after 
which  no  further  observations  are  recorded. 

5.  Wederstrandt's  patient  (shot)  recovered  from  his  injury, 
and  died  at  the  Charity  Hospital  seven  years  after  from  diar- 
hcea.  He  had  marked  aneurismal  symptoms,  with  paralysis 
and  atrophic  changes  in  the  arm,  up  to  the  time  of  his  death, 
and  at  the  autopsy  a  well-marked  varicose  aneurism  between 
the  subclavian  artery  and  vein  was  found. 

6.  Fischer's  case  (stab)  recovered  from  the  injury,  with  per- 
sistent signs  of  aneurism,  but  was  living  one  year  after  the 
injury,  after  which  he  passed  out  of  observation. 

7.  Kirsch's  patient  (shot)  recovered  from  the  immediate  effects 
of  the  injury,  remained  under  observation  two  and  one-half 
months,  but  was  not  improved,  and  was  discharged  with  active 
aneurismal  signs.  He  suffered  also  from  persistent  disturbances 
in  the  circulation,  and  innervation  of  arm  and  hand ;  had  diffi- 
culty in  moving  his  fingers. 

8.  Smith's  patient  (stab)  recovered  from  the  immediate  effects 
of  the  injury,  the  wound  healing  in  three  weeks.  Signs  of  vari- 
cose aneurism  existed  seven  months  after  the  injury,  with  dis- 
turbances in  the  circulation  of  the  arm  under  certain  conditions. 
Eight  months  (?)  after  the  injury  he  was  compelled  to  return  to 
the  infirmary,  with  signs  of  obstruction  in  the  circulation  of  the 
arm.  The  arm  on  the  affected  side  had  suddenly  become  cold 
and  oedematous,  and  in  a  few  days  gangrene  of  the  ring  and 
little  finger,  with  part  of  the  forearm  and  hand,  had  set  in.  He 
gradually  recovered  from  the  sloughing  without  serious  consti- 
tutional disturbance.  The  radial  pulse,  which  had  ceased  to 
beat  from  the  time  of  the  injury,  now,  strange  to  say,  returned, 
when  gangrene  was  established.  The  aneurismal  signs  still 
persisted  actively  when  discharged. 

9.  Arango's  patient  recovered  from  the  immediate  effects  of 
the  injury,  which  was  accompanied  by  marked  circulatory  dis- 
turbances in  the  arm,  but  no  sloughing.  He  was  so  much  dis- 
turbed by  the  noises  in  the  aneurism  that  he  had  to  be  carried 
to  the  vicinity  of  a  torrent  in  order  to  drown  the  sounds  and 
thus  secure  sleep.     This  intense  disturbance  subsided  in  forty 


268  MAT  AS, 

days.  Two  months  afterward  the  aneurismal  signs  continued, 
though  much  diminished.  Ten  years  later,  the  patient's  friends 
reported  him  "  feeling  perfectly  well." 

10.  Will's  patient  (stab  wound  of  subclavian  vessels  compli- 
cated by  perforation  of  pleura)  was  stabbed  on  May  7,  1875  ;  left 
hospital  on  19th,  had  first  secondary  bleeding  while  travelling; 
on  25th,  last  and  fatal  hemorrhage.  Patient  expired  as  the 
operator  had  begun  an  incision  to  expose  the  bleeding  vessel 

11.  Wedekind's  patient  (stab)  recovered  from  the  immediate 
efTects  of  the  injury  and  was  in  excellent  general  condition 
seven  months  after,  but  the  aneurismal  signs  remained  una- 
bated, and  he  suffered,  under  special  conditions,  from  transitory 
disturbances  in  the  sensibility  of  the  arm  and  hand,  caused 
apparently  by  interference  with  circulation. 

Under  the  category  of  unoperated  cases  we  could  also  prop- 
erly include  Wattmann's  case.  This  case  is  most  interesting  as 
showing  that  even  after  a  latent  period  of  thirty-one  years,  in 
which  the  patient  was  apparently  well,  the  lesion  finally  became 
active  and  gave  rise  to  fatal  complications. 

Thus  we  find  that  in  ii  out  of  12  cases  which  were  treated 
primarily  by  the  expectant  plan,  1 1  recovered  from  the  imme- 
diate effects  of  the  injury,  and  their  wounds  healed  without 
secondary  hemorrhage,  except  one  (Will's  case),  by  simple 
measures  of  compression  with  bandages,  rest,  etc.  But  it  is  to 
be  noticed,  also,  that  only  in  one  or  possibly  two  (Larrey  and 
Arango)  was  there  reason  to  believe  that  the  lesion  had  been 
cured.  In  all,  the  signs  of  arterio-venous  aneurism  remained 
active,  and  in  several  the  murmurs  and  sounds,  after  many  years, 
were  so  annoying  that  the  patients  applied  for  relief  on  this  ac- 
count— in  one  case  more  than  ten  years  after  the  injury  (Sanson's 
case).  In  six  cases  (Larrey,  Kirsch,  Wederstrandt,  Smith, 
Fischer,  Wedekind)  permanent  circulatory  and  trophic  disturb- 
ances persisted  in  the  arm,  not  only  from  associate  injury  to 
brachial  plexus,  but  from  interference  with  circulation  ;  in  one 
(Smith's  case)  gangrene  set  in,  with  loss  of  part  of  the  extremity 
(fingers,  hand,  and  forearm),  more  than  seven  months  after  the 
patient  had  recovered  from  the  injury.     In  the  other  unoperated 


TRAUMATIC     ARTERIO -VENOUS    ANEURISMS.  269 

cases,  with  the  exception  of  three  (Wattmann's  succumbed  thirty- 
two  years  afterward,  after  thirty  years  of  latency;  Will's  died  from 
secondary  hemorrhage  three  weeks  after  the  injury,  and  Smith's, 
from  gangrene  of  extremity  seven  months  after),  it  is  only  fair  to 
state  that  the  abnormal  conditions  of  the  circulation  created  by 
this  lesion  were,  with  the  exception  of  the  annoyances  and  dis- 
turbances previously  referred  to,  fairly  well  tolerated,  and  were 
not  incompatible  with  a  long  survival  and  active  life.  It  is  well 
to  note,  however,  that  in  at  least  six  of  these  cases  the  patients 
were  last  seen,  or  passed  out  of  the  observation  of  the  surgeons 
who  reported  them,  within  a  few  weeks  or  months  after  the  in- 
jury, while  the  lesion  was  still  active,  and  too  soon  to  permit 
any  definite  conclusions  as  to  the  final  outcome  of  the  injury 
(Berard,  a  few  weeks;  Smith,  seven  or  eight  months;  Fischer, 
one  year;  Letenneur,  twenty-one  days;  Kirsch,  two  and  one- 
half  months;  Wedekind,  seven  months).' 

The  Operated  Cases  and  Results. 

In  4  only  of  the  15  cases  was  an  operation  resorted  to;  in  3 
cases  ligation  of  the  vessel  was  made  imperative  by  the  occur- 
rence of  violent  secondary  hemorrhage  following  shortly  after 
the  injury,  and  in  only  i  (my  own)  was  the  operation  deliber- 
ately performed  in  anticipation  of  future  complications.  Three 
out  of  these  4  cases  permanently  recovered  except  Wattman's 
patient,  operated  in  1840,  who  died  of  secondary  hemorrhage 
twenty-three  days  and  thirteen  hours  after  the  ligation  of  the 
third  portion  of  the  subclavian.  This  case,  which  is  often 
referred  to  as  a  case  of  traumatic  aneurism  of  the  subclavian 
artery  at  its  junction  at  the  axillary,  is  especially  interesting  to 
us  in  this  connection,  because  it  illustrates  the  possible  transfor- 
mation of  a  passive  and  benign  arterial  varix  into  a  rapidly 
growing  and  malignant  aneurism  of  the  artery  after  a  long  lapse 
of  time.  In  this  case  a  gunshot  injury  was  inflicted  in  1809 
from  which  the  patient  recovered  without  any  great  disturbance 
except  cramps  in  the  arm.  From  1809  to  1840,  thirty-one  years, 
during  which  the  patient  was  engaged  in  active  military  service, 
he  suffered   no  serious  inconvenience.     In   1840  an  aneurismal 


2/0  MAT  AS, 

tumor  was  developed  for  the  first  time  under  the  clavicle.  This, 
however,  did  not  enlarge  for  two  years.  In  1842  erysipelas  and 
phlebitis  set  in,  and  the  tumor  rapidly  grew  to  threatening  pro- 
portions. Under  these  conditions,  Wattman  found  it  necessary 
to  operate.  Two  ligatures  were  applied  between  the  scaleni 
and  the  tumor,  none  to  the  vein  ;  secondary  hemorrhage  oc- 
curred at  the  point  of  ligature,  which  caused  the  death  of  the 
patient.  A  large  varicose  sac  was  found  at  the  post-mortem, 
which  communicated  with  both  the  artery  and  vein. 

In  Rotter's  case  (1892)  the  signs  of  arterio- venous  aneurism 
developed  almost  immediately  after  a  stab  injury;  profuse  pri- 
mary bleeding  followed.  Rotter  advised  immediate  operation,  but 
the  patient  would  not  consent  until  after  a  nearly  fatal  secondary 
hemorrhage  occurred  on  the  ninth  day  at  midnight,  when  Rot- 
ter cut  down  upon  the  vessels  and  ligated  them  outside  of  the 
scalenus  after  resecting  the  clavicle.  The  knife  had  penetrated 
one  inch  below  the  middle  of  the  left  clavicle,  causing  a  sharp- 
edged  oblique  wound,  two-thirds  of  an  inch  long.  After  re- 
secting the  clavicle  and  displacing  it  upward,  he  was  able,  by 
following  the  track  of  the  wound,  to  insinuate  his  fingers  behind 
both  vessels  as  they  emerged  on  the  outer  side  of  the  scalenus, 
and  by  hooking  his  fingers  behind  them  and  dragging  them 
forward  was  able  to  control  the  bleeding  until  the  artery  and 
vein  had  been  ligated  above  and  below  the  point  of  injury.  The 
patient,  though  much  shocked,  made  a  good  recovery.  The  clavi- 
cle was  sutured  back  into  position.  The  arm  became  cadaveric- 
ally  pale  and  cold,  but  the  circulation  was  finally  re-established. 

Veiel's  case  is  also  very  interesting  ;  the  patient,  aged  twenty- 
three  years,  was  stabbed  in  the  right  shoulder  on  May  14.  1894. 
Wound  one-third  of  an  inch  below  the  middle  of  the  clavicle. 
Profuse  hemorrhage  and  syncope  when  bleeding  stopped  spon- 
taneously. Temperature,  about  103°,  gradually  subsiding  to 
normal  on  the  ninth  day.  Profuse  secondary  hemorrhage  took 
place  at  midnight(ninth  to  tenth  day)  while  the  patient  was  asleep. 
He  had  signs  of  arterio-venous  aneurism,  which  were  observed 
for  the  first  time  on  the  tenth  day,  when  septic  pneumonia  set 
in.     Fearing   the    repetition   of  the   hemorrhage,  which  would 


TRAUMATIC    A  KT  E  R  I  O-V  E  NO  US    ANEURISMS.  27I 

have  been  fatal,  an  operation  was  performed.  Following  the 
track  of  the  wound  an  incision  was  made  into  a  pocket  situ- 
ated below  the  clavicle,  but  a  flood  of  blood  followed  which 
could  only  be  controlled  by  packing  the  cavity.  While  this 
was  being  done  the  third  division  of  the  subclavian  was  exposed 
and  ligated  outside  of  the  scalenes,  but  upon  diminishing  the 
pressure  and  removing  the  pack  in  the  wound  below  the  clav- 
icle, bleeding  followed,  which  was  not  controlled  until  the  vein 
had  been  exposed  and  ligated  in  the  sac  above  and  below  the 
injury.  A  third  tributary  vein,  which  continued  to  bleed  freely 
after  the  main  trunk  had  been  secured,  had  also  to  be  ligated. 
Hsemoptysis  and  pyaemic  pneumonia,  with  temperature  of  104°, 
threatened  the  life  of  the  patient  for  several  days.  Fever  ceased 
only  on  the  twenty-fifth  day  after  the  injury,  and  only  after  a 
large  phlebitic  phlegmon  of  the  arm  on  the  affected  side  had 
been  opened  and  a  septic  venous  clot  removed.  The  wound 
had  healed  and  the  patient  was  discharged  two  and  a  half 
months  after  the  operation  in  a  very  satisfactory  general  condi- 
tion. The  circulation  in  the  arm  and  its  nutrition  were  affected 
permanently  and  very  seriously.  Eight  and  a  half  months 
after  the  operation  anaesthesia  and  trophic  changes,  with  a 
loss  of  thermic  sense,  existed,  leaving  the  arm  in  a  state  of 
functional  disability. 

These  four  operated  cases  (including  my  own  fully  reported 
in  the  first  section  of  this  paper)  resulted  in  three  recoveries, 
the  only  death  (Wattmann's)  being  due  to  secondary  hemor- 
rhage following  a  ligature  applied  under  very  disadvantageous 
conditions  and  with  the  old  septic  technique.  In  2  out  of  the  3 
cured  cases  serious  functional  disability  followed  after  the  inter- 
vention, though  in  my  case,  in  which  partial  gangrene  of  the  hand 
and  forearm  occurred  after  operation,  there  was  a  coincident 
paralysis  of  the  arm  from  injury  to  the  brachial  plexus. 

Effects  of  the  Arterio-venous  Lesion  of  the  Subclavian   Vessels 
upon  the  Circulation  of  the  Upper  Limb. 

The  effect  of  accidental  and  surgical  occlusion  of  the  sub- 
clavian vessels  upon  the  circulation  of  the  arm  is  the  cause  of 


2/2  MAT  AS, 

much  concern  in  these  cases.  In  analyzing  the  individual  re- 
ports of  these  fifteen  arterio-venous  injuries  or  aneurisms  we 
are  impressed  by  the  fact  that  in  a  large  majority  the  effects  of 
the  arterial  ischaemia  and  coincident  venous  obstruction  were 
immediately  perceived.  Suppression  of  the  brachial  and  radial 
pulse  are  noted  in  the  majority  of  the  cases  of  which  full  obser- 
vations have  been  recorded;  in  many,  great  pallon  lividity  of 
the  skin,  ecchymoses,  coldness  of  the  surface,  functional  dis- 
ability, numbness,  parsesthesia,  oedema,  etc.,  are  recorded  as  the 
immediate  effects  of  the  injury.  In  two,  extensive  interference; 
in  one  of  these  spontaneously  (Smith's  case);  in  the  other,  after 
the  ligation  of  the  artery  and  lateral  suture  of  the  vein  (Matas). 
That  the  danger  of  sloughing  is  not  to  be  lightly  considered  is 
well  shown  in  my  case,  in  which,  after  the  ligature  of  the  second 
division  of  the  artery,  followed  by  torsion  of  the  proximal  end 
(following  VVyeth's  suggestion),  and  after  simple  lateral  suture 
of  the  vein  purposely  done,  so  as  not  to  interrupt  the  venous 
current,  complete  arterial  ischaemia  followed,  causing  an  exten- 
sive dry  sphacelation  of  the  several  fingers,  part  of  the  hand, 
and  forearm.  That  this  was  due  to  complete  interference  with 
the  arterial  and  not  the  venous  supply  of  the  limb  is  proven  by 
the  character  of  the  gangrene  (dryj  and  pallor  of  the  skin.  This 
result  is  important  because  the  ligation  was  performed  with  the 
most  aseptic  technique  and  with  absorbable  kangaroo  ligatures, 
and  the  wound  healed  per  primam.  The  complete  ischaemia  of 
the  arm  can  only  be  accounted  for  by  the  torsion  which  was 
applied  to  the  proximal  end  before  ligation,  which  no  doubt 
interfered  with  the  collateral  supply  from  the  branches  of  the 
thyroid  axis,  superior  intercostal,  and  possibly  the  internal 
mammar)^  This  extra  precaution,  which  was  calculated  to 
diminish  the  risk  of  secondary  hemorrhage,  should  be  avoided 
if  possible  in  future  operations. 

We  have  already  referred  to  the  tropho-paralytic  phenomena 
which  in  some  cases  permanently  impaired  the  usefulness  of  the 
arm  as  a  result  of  circulatory  disturbances  independently  of  in- 
jury to  the  brachial  plexus  (Veiel's  case  is  probably  the  most 
notable   in   this  respect).      That   the   danger   of  sloughing  is 


TRAUMATIC    A  RT  E  R  I  O-V  EN  O  US    ANEURISMS.  273 

greater  in  double  (arterio-venous)  injuries  than  after  interfer- 
ence with  arterial  circulation  alone  is  well  shown  by  the  com- 
parative statistics  of  the  two  classes  of  injuries.  Le  Fort,  in 
his  learned  and  careful  study  of  223  ligations  of  the  subclavian 
artery  for  all  causes  (published  in  1867),  was  able  to  find  only  4 
cases  in  which  gangrene  occurred,  and  this  was  limited  chiefly 
to  the  fingers  (1.7  per  cent.).  These  are  the  cases  reported  by 
O'Reilly,  White,  Blizzard,  Terrier,  the  last  complicated  by  in- 
jury to  the  brachial  plexus.  Von  Bergmann  (1877),  ^^  studying 
the  effects  of  injury  to  the  subclavian  from  the  same  point  of 
view,  states  that  in  90  cases  of  ligation  of  the  subclavian,  gan- 
grene of  the  fingers  occurred  in  3  cases- (3;}  per  cent.),  and  in 
these  this  result  was  attributable  largely  to  the  extensive  con- 
tusion of  the  skeleton  and  soft  parts  about  the  shoulder  girdle. 
In  this  respect  the  risk  of  gangrene  cannot  compare  with  the 
greater  frequency  of  this  result  in  similar  ligations  of  the  vessels 
at  the  groin. 

It  is  also  well  established  that  gangrene  is  much  less  frequent 
after  ligations  of  the  third  division  of  the  subclavian  above  the 
clavicle  than  after  the  ligation  of  the  axillary  when  this  is  done 
in  the  wound. 

For  instance,  Le  Fort  {/oc.  cit.),  in  a  study  of  42  cases  of 
axillary  aneurisms,  notes  5  cases  in  which  gangrene  occurred 
as  a  direct  result  of  the  traumatism  without  ligation,  and  in  6 
in  which  the  gangrene  followed  the  ligature  applied  in  the 
wound  at  the  time  of  injury. 

The  gravity  of  the  double  (arterio-venous)  injuries  of  the 
subclavian  vessels  from  this  point  of  view  will  now  be  appre- 
ciated when  we  recall  the  facts  gathered  from  our  statistics  that 
I  in  II  unoperated  cases  sloughed  (9  +  per  cent.),  and  that  in 
I  of  the  4  operated  cases  (25  per  cent.)  this  unfortunate  result 
followed. 

The  extent  of  the  traumatism  in  the  operated  cases  was,  it 
must  be  remembered,  greater  than  in  the  non-operated,  since 
the  operation  in  3  of  the  4  was  necessitated  by  secondary 
hemorrhage  or  other  grave  complicating  lesion,  whereas  second- 
ary hemorrhage  occurred  in  only  i  of  the  ii  unoperated  cases. 

Am  Surg  i8 


2/4  MATAS, 

To  summarize  the  liability  to  gangrene,  grossly  stated  and 
without  reference  to  special  modifying  conditions,  it  would  be  as 
follows  for  the  various  lesions:  Arterio-venous  injuries  of  both 
subclavian  vessels  (artery  and  vein),  including  ligations,  13.5  per 
cent.  ;  after  ligature  of  subclavian  artery  (third  division)  1.7  per 
cent. (Le  Fort);  or  3^^  per  cent,  (von  Bergmann)  ;  after  obliter- 
ative  injuries  of  the  axillary,  26.8  per  cent.  This  last  per- 
centage relates,  however,  to  cases  reported  before  1867,  and 
would  no  doubt  be  much  improved  by  later  statistics  ;  the  con- 
trast between  the  axillary  and  subclavian  injuries  is,  neverthe- 
less, significant. 

Practical  Concbisions. 

As  a  result  of  the  study  of  the  arterio-venous  aneurisms  of 
the  subclavian  vessels  which  we  have  summarized  in  this  con- 
tribution, we  find  that  this  class  of  injuries  can  be  separated 
clinically  and  surgically  into  three  distinct  and  well-defined 
groups: 

1.  The  immediately  fatal  cases  in  which  death  follows  so 
quickly  after  the  injury  from  the  effect  of  the  primary  hemor- 
rhage and  shock  that  no  effective  surgical  assistance  can  be  ren- 
dered. These  probably  constitute  the  largest  proportion  of  cases, 
especially  in  military  practice,  though  an  exact  estimate  cannot 
be  obtained.  It  is  also  probable  that  the  vast  majority  of  inju- 
ries involving  the  first  and  second  divisions  are  fatal  primarily, 
and  are  to  be  included  in  this  group,  except  when  the  injuries 
are  caused  by  small  projectiles  or  sharp-pointed  weapons. 

2.  In  this  second  group,  primary  hemorrhage  may  be  very 
great,  but  spontaneous  or  temporary  haemostasis  occurs  in  the 
syncopal  state,  which  favors  the  formation  of  a  provisional 
thrombus.  In  this  class  of  cases  two  events  may  occur  which 
will  profoundly  modify  the  prognosis.  In  the  one  case  {a)  sec- 
ondary bleeding  will  set  in  within  a  few  hours  or,  more  often, 
days  (usually  within  the  first  week),  with  disastrous  conse- 
quences, unless  the  patient  is  rescued  by  prompt  operation  or 
other  form  of  intervention.  The  other  alternative  (/;)  justifies 
the  formation  of  a  separate  group. 


TRAUMATIC    A  RT  ER  I  O-V  E  N  O  US    ANEURISMS.  2/5 

3.  In  this  group  the  primary  hemorrhage  may  also  be  exces- 
sive, but,  as  a  rule,  is  moderate  and  is  readily  controlled  by  press- 
ure, or  may  be  spontaneously  arrested  as  in  group  2.  More 
often  there  is  no  syncope,  because  the  external  hemorrhage  is 
slight.  There  may  be  a  large  haematoma.  No  secondary 
hemorrhage  occurs,  the  wound  heals  up,  leaving  a  well-defined 
and  permanent    arterio-venous  aneurism. 

The  arterio-venous  circuit  is  usually  promptly  established  by 
direct  inosculation  between  the  artery  and  vein  (aneurismal 
varix),  or  by  means  of  an  intermediary  sac  (varicose  aneurism), 
the  fistulous  communication  between  the  vessels  acting  in  both 
cases  as  a  safety-valve  by  which  the  dangers  of  further  extrava- 
sation are  to  a  large  extent  permanently  avoided. 

Rotter,  in  his  paper  published  in  1893,  analyzes  13  cases  of 
stab  wound  of  the  subclavian  vessels,  5  of  which  were  arterio- 
venous, including  the  one  which  he  reports,  in  which  he  oper- 
ated for  secondary  hemorrhage  following  an  injury  to  both 
vessels. 

He  found  that  in  6  cases  the  hemorrhage  was  spontaneously 
arrested,  and  no  secondary  hemorrhage  occurred  ;  but  in  all  of 
these  secondary  traumatic  aneurism  developed,  which  impaired 
the  usefulness  of  the  arm,  either  partially  or  completely,  and 
led  to  grave  secondary  complications  which  subsequently  im- 
perilled life. 

In  seven  cases,  the  larger  number,  repeated  secondary  hem- 
orrhage occurred,  and  the  result  was  far  more  serious,  for 
all  these  patients  except  Rotter's  (an  arterio-venous  injury) 
died,  and  this  one  was  saved  only  by  prompt  and  desperate 
operation  undertaken  at  midnight.  As  a  result  of  this  inquiry. 
Rotter  advocates  immediate  operation — i.  e.,  ligation  of  the  in- 
jured vessels  at  the  bleeding-point  as  quickly  as  possible  after 
the  patient  has  recovered  from  primary  shock  and  hemorrhage 
without  waiting  for  the  appearance  of  the  secondary  hemor- 
rhage which  might  prove  fatal.  The  only  objection  to  Rotter's 
recommendation  is  that  it  is  based  upon  the  observation  of 
mixed  arterial  and  arterio-venous  injuries,  and  not  sufficient 
stress  is  laid  upon  the  more  favorable  tendency  displayed  by  the 


276  MAT  AS, 

arterio-venous  injury  when  these  show  an  early  disposition  to 
form  aneurismal  varices. 

The  relative  benignity  of  arterio-venous  aneurisms  when  fully 
developed — i.  e.,  when  the  communication  between  the  artery 
and  the  vein  has  become  distinctly  and  permanently  estab- 
lished— has  led,  as  Poinsot  correctly  remarked  in  1882,  to  the 
general  acceptance  of  a  fallacious  doctrine  that  in  wounds  of  a 
single  vessel,  such  as  the  subclavian  artery,  the  simultaneous 
lesion  of  the  satellite  vein  was  a  safeguard  to  the  life  of  a 
patient. 

For  instance,  Moore/  in  commenting  upon  Larrey's  case, 
said  "  his  [the  patient's]  life  appears  to  have  been  saved  by  the 
singular  circumstance  that  the  vein  was  also  pierced  by  the 
lance  [sabre],  which  wounded  the  artery.  The  blood  from  the 
latter  vessel,  when  restrained  from  passing  through  the  ex- 
ternal wound,  escaped  into  the  vein,  and  was  thus  saved  to  the 
system  until  the  wound  healed."  The  explanation,  says  Poinsot, 
is  as  fantastic  as  the  pretended  benignity  of  the  injury  is  con- 
testable. 

If  the  simultaneous  lesion  of  the  artery  and  vein  is  appar- 
ently less  dangerous  statistically  than  injury  of  the  artery 
alone,  this  is  due  to  the  fact  that  in  many  immediately  fatal 
cases  the  existence  of  the  double  injury  is  not  recognized  until 
after  death  or  only  in  the  cases  in  which  the  patient  survives 
and  the  anastomosis  has  had  time  to  form  or  an  operation  has 
been  performed  for  repeated  hemorrhage.  Whatever  the  doubts 
entertained  on  the  subject,  the  cases  of  Will,  Rotter,  and  Veiel 
alone  suffice  to  prove  that  the  old  teaching  as  to  the  relative 
benignity  of  double  injuries  is  not  to  be  trusted.  One  fact,  how- 
ever, must  be  admitted,  as  we  have  conclusively  shown  in  our 
table,  and  that  is  that  once  the  arterio-venous  connections  have 
been  firmly  established  these  injuries  as  a  class  are  less  danger- 
ous to  life  than  the  traumatic  aneurisms  involving  the  artery 
alone. 

In  dealing  with  these  cases  practically  there  are  three  ques- 

1  Holmes'  System  of  Surgery.     Edit.  1894. 


TRAUMATIC     A  RT  E  R  I  0-V  ENO  U  S    ANEURISMS.  2/7 

tions  that  now  present  themselves  for  discussion  or  considera- 
.  tion  : 

I.  What  is  the  best  treatment  that  can  be  applied  to  arrest 
the  primary  bleeding  at  the  time  of  injury? 

2  After  the  arrest  of  the  primary  hemorrhage,  and  the 
patient  has  rallied  from  the  shock,  and  it  is  evident  that  one  or 
both  vessels  have  been  injured,  shall  we  proceed  immediately 
to  secure  the  bleeding-point  or  wait  for  future  developments, 
hoping  that  the  wound  will  heal ;  that  no  secondary  bleeding 
will  occur,  and  that  if  it  is  a  double  injury  a  permanent  arterio- 
venous communication  will  be  established? 

3.  After  the  existence  of  an  arterio-venous  aneurism  is  fully 
established  and  the  wound  has  apparently  healed,  shall  we  con- 
sider the  patient  out  of  danger  and  discharge  him  with  this 
lesion  in  an  active  state,  trusting  to  Nature's  tolerance  of  this 
condition  and  to  the  remote  possibility  that  it  may  be  spon- 
taneously cured  ? 

We  may  now  briefly  summarize  our  conclusions  on  these  three 
points  seriatim  : 

The  treatment  of  arterio-venous  injuries  of  the  first  division 
of  the  subclavian  need  scarcely  be  considered.  The  cases  of 
survival  after  the  immediate  effects  of  such  an  injury  must  be 
rare  indeed.  Nevertheless,  wounds  inflicted  by  very  small 
calibre  bullets  (Lettenneur's  case)  or  with  narrow-pointed 
weapons  may  give  rise  to  comparatively  small  hemorrhages 
which,  being  spontaneously  arrested  and  circumscribed,  will  end 
in  aneurismal  varices.  It  is  quite  possible  that  in  future  cases 
of  this  kind  in  this  locality  may  be  more  frequently  recorded 
than  in  the  past,  especially  since  the  introduction  of  hard,  small 
calibre  projectiles  in  modern  warfare.  It  is  evident  that  in  this 
division  of  the  artery  no  operative  treatment  is  permissible,  the 
danger  and  magnitude  of  the  intervention  overshadow  the  pos- 
sible danger  of  the  lesion,  which,  when  reduced  to  the  condi- 
tion of  a  simple  varix,  is  undoubtedly  compatible  with  a  long 
tolerance  and  survival. 

In  dealing  with  arterio-venous  traumatisms  of  the  second  and 
third  divisions  of  the   subclavian   the  conditions  are  different. 


278  MATAS, 

Here  the  vessels  are  comparatively  accessible,  and  notwith- 
standing the  grave  and  formidable  character  of  the  undertaking 
it  is  quite  possible  after  the  resection  of  the  clavicle,  as  first 
suggested  by  Langenbeck,  and  practised  by  Bergmann,  Rotter, 
Halsted,  the  author,  and  others,  to  bring  the  vessels  into  view 
and  to  ligate  them. 

In  dealing  with  the  first  condition — /.  e.,  a  bleeding  patient — 
it  is  evident  that  all  attempts  at  radical  operation  on  the  spot 
cannot  be  considered  in  ordinary  circumstances.  The  first  in- 
dication, then,  is  to  arrest  the  bleeding,  and  this  is  best  done 
by  (i)  digital  compression  over  a  compress  or  in  the  wound, 
(2)  by  packing  the  wound,  if  it  is  a  penetrating  cut,  and  holding 
the  pack  firmly  wedged  in  the  wound  by  suturing  the  edges  of 
this  over  the  pack  ;  or,  again,  (3)  by  hermetically  sealing  the 
wound  with  a  continuous  stitch,  as  Rotter  suggests.  This  pro- 
cedure, followed  by  a  firm  compression  bandage,  will  usually 
suffice  to  arrest  the  external  bleeding  until  the  patient  is  taken 
to  a  hospital  or  other  convenient  place,  where  a  flat  bag,  filled 
with  lead-shot,  and  held  over  the  injured  area  with  an  elastic 
bandage,  will  usually  prevent  any  further  primary  (external) 
bleeding. 

After  the  patient  has  rallied  from  hemorrhage  and  shock,  then 
the  question  arises,  Shall  we  operate  and  when  ?  Shall  we  wait 
for  a  dangerous,  if  not  fatal,  secondary  hemorrhage  to  occur,  or 
prevent  this  by  operation?  On  this  point  there  are  differences 
of  opinion.  No  one  will  question  the  propriety  of  early  inter- 
vention in  cases  of  arterial  injury  with  the  formation  of  a  large, 
increasing  and  pulsating  haematoma.  Here  the  general  princi- 
ples which  have  guided  the  surgeons  in  the  past  are  applicable 
with  still  greater  reason.  The  wounded  vessels  must  be  sought 
for  at  the  bleeding-point  if  possible.  Bergmann's  rule  in  refer- 
ence to  subclavian  injuries,  confirmed  by  Le  Fort  and  Poinsot, 
and  more  recently  emphasized  by  Rotter,  in  reference  to  arterio- 
venous injuries,  has  now  become  a  command  in  this  class  of 
cases. 

"  The  ligature  of  the  artery  should  be  performed  as  soon  as 
the  patient  has  recovered  from  shock;   if  possible  on  the  day  of 


TRAUMATIC    ARTERIO -VENOUS    ANEURISMS.  279 

the  injury;  and  the  vessel  should  be  secured  in  the  wound  and 
tied  above  and  below  the  injured  point"  (Rotter).  While  we 
recognize  the  great  force  of  a  surgical  canon  which  is  based 
upon  sound  reason  and  experience,  it  must  be  recognized,  with 
Wedekind  and  other  recent  writers,  that  there  are  conditions 
which  justify  delay,  more  especially  in  those  cases  in  which  the 
subclavian  wound  implicates  both  vessels. 

It  must  be  recognized  that  even  a  reasonable  suspicion  or 
positive  evidence  of  an  injury  to  both  vessels  (artery  and  vein) 
is  not  sufficient  to  justify  a  suspension  of  the  above  stated  rule 
of  practice,  but  that  the  development  of  positive  signs  of  an 
established  arterio-venous  anastomosis  does  justify  delay  when 
the  patient  can  be  kept  under  constant  observation  and  intelli- 
gent supervision.  But  as  the  signs  of  arterio-venous  anasto- 
mosis are  often  delayed,  other  criteria  must  be  depended  upon 
to  decide  the  question  of  intervention  or  abstention.  Of 
these  modifying  conditions,  the  following  are  probably  the 
most  important  : 

I.  The  quantity  of  blood  lost  in  the  primary  hemorrhage 
whether  profuse,  moderate,  or  small.  2.  The  extent  of  the  sub- 
cutaneous haematoma.  3.  The  fact  that  the  hemorrhage  was 
arrested  with  difficulty,  or  ceased  spontaneously  and  completely, 
after  syncope.  4.  The  tendency  to  recurrence  of  early  inter- 
mediate hemorrhage,  "  warning  hemorrhages,"  which  are  the 
invariable  precursors  of  the  more  formidable  and  fatal  second- 
ary hemorrhages.  5.  The  development  of  positive  signs  of  an 
established  arterio-venous  communication. 

If  the  primary  hemorrhage  is  profuse  and  obstinate  ;  if  it  tends 
to  recur  with  the  restoration  of  the  circulation  after  shock;  if  the 
hrematoma  is  extensive  and  progressive,  then  there  can  be  no 
hesitation  as  to  the  urgency  of  surgical  action,  whether  the  evi- 
dence points  to  a  single  or  a  double  injury  of  the  associated 
vessels. 

If,  on  the  other  hand,  the  primary  bleeding  is  moderate  and  is 
readily  controlled  by  pressure,  or  ceases  spontaneously  and  com- 
pletely, and  there  is  no  extensive  or  progressive  hrematoma ;  if 
there  is  no  tendency  to  bleeding  upon  the  removal  of  the  dress- 


28o  MAT  AS, 

ings,  then  delay,/,  e.,  armed  expectation,  is  permissible.  If,  in 
addition  to  the  favorable  signs,  there  is  an  early  development 
of  the  signs  of  an  arterio-venous  anastomosis,  then  a  conserva- 
tive attitude  is  more  than  ever  justifiable, /wf/V/^^/,  always,  that 
the  patient  can  be  kept  under  competent  and  skilled  surgical 
surpervision  (Wedekind). 

As  to  the  last  point,  it  is  evident  that  even  under  the  most 
favorable  conditions,  and  with  the  most  skilful  assistance,  the 
ligation  of  a  wounded  subclavian  is  a  formidable  undertaking, 
always  fraught  with  great  danger,  and  demanding  for  its  succes- 
ful  accomplishment  all  the  resources  of  the  technique  and  the  cool 
judgment  which  come  only  with  long  training;  and  if  these  are 
wanting  at  the  time,  it  is  plain  that  expectancy  and  palliation, 
with  pressure,  rest,  and  ice,  is  the  only  conservative  course  to 
pursue  until  the  patient  has  rallied  sufficiently  to  be  transported 
to  a  place  where  the  necessary  conditions  for  a  radical  operation 
can  be  obtained. 

Finally,  if  the  patient  survives  the  first  hemorrhage  and 
shock,  and  there  is  no  recurrence  of  hemorrhage,  and  the 
wound  heals,  with  the  formation  of  a  simple  aneurismal  varix, 
what  is  the  proper  course  to  pursue  ?  On  this  phase  of  the 
subject  it  may  be  safely  asserted  that  the  consensus  of  surgical 
opinion  first  formulated  thirty-six  years  ago,  when  Letenneur's 
case  was  discussed  at  the  Societe  de  Chirurgie,  1867,  has  crystal- 
lized-in  definite  form  in  favor  of  nonintervention. 

The  statistics  which  we  furnish  in  this  paper — the  most  com- 
plete list  of  the  reported  instances  of  this  rare  lesion  which  has 
thus  far  appeared — tend  to  confirm  the  arguments  of  the  "let- 
well-enough-alone"  policy,  in  so  far  as  they  demonstrate  that  in 
at  least  ii  of  the  15  cases  the  patient  survived  the  immediate 
effects  of  the  injury  and  of  the  arterio-venous  aneurism  that  fol- 
lowed it  for  variable  and  often  long  periods  of  time.  The  study 
of  these  cases  shows,  however,  that  while  the  active  persistence 
of  the  lesion  is  compatible  with  a  long  survival  (ten  years  in  two 
and  as  long  as  thirty-two  years  in  one),  they  also  show  that  in 
the  vast  majority  (all  buttwo)the  lesion  persisted  in  an  active  state 
in  spite  of  sustained  efforts  to  cure  it ;  in  many,  the  final  outcome 


TRAUMATIC    A  RT  E  R  I  0-V  ENO  US    ANEURISMS.  281 

could  not  be  ascertained,  but  in  others  disastrous  consequences 
followed  in  consequence  of  disturbances  of  the  circulation  in  the 
extremity,  which  shows  that  arterio-venous  aneurisms  of  the  sub- 
clavians,like  those  of  other  large  trunks,  persist  as  pathological 
conditions,  which  are  only  tolerated  by  the  organism ,  and  remain 
a  vulnerable  point  in  the  vascular  system,  which  may  lead — even 
after  years  of  toleration — to  disaster  and  death.  These  facts 
alone  would  justify  a  more  aggressive  attitude  toward  this  form 
of  vascular  lesion  on  the  part  of  sufgeons  were  it  not  that  the 
dangers  of  the  operation  required  to  eradicate  it  are  not  to  be 
underrated,  even  with  all  the  advantages  of  the  modern  technique. 

In  conclusion,  while  recognizing  that  a  decision  in  this  matter 
must  rest  largely  with  the  personal  equation  and  experience  of 
the  operator,  we  believe  that  in  all  fully  established  arterio- 
venous aneurisms  which  are  well  tolerated  and  give  rise  to  little 
disturbance — and  are  presented  by  patiertts  who  can  be  kept 
under  periodical  observation — the  old  rule  of  non-intervention 
is  still  in  order  and  should  be  followed.  On  the  other  hand,  we 
believe,  with  Delbet,  that  with  the  improved  conditions  of  the 
present  day  the  indications  for  interference  have  broadened,  and 
that  whenever  the  lesion  is  not  well  tolerated,  and  gives  rise  to 
serious  circulatory  or  other  disturbance,  it  is  justifiable  to  operate 
with  the  view  of  extirpating  the  lesion,  especially  when  situated 
in  the  more  accessible  third  and  second  divisions  of  the  artery. 

In  addition  to  the  references  given  in  the  table  of  cases,  the 
following  texts  have  been  referred  to  : 

1.  Broca,  P.     Des  Anevrysmes.     Paris,  1856. 

2.  Le  Fort,  L.     Article  "Anevrysme,"  Diet.  Dechambre,  V.  iv.,  1866. 

3.  Le  Fort,  L.    Article  "  Sous-claviere,"  Diet.  Dechambre,  Troisieme  serie,  V.  x.,  1881 

4.  Poinsot,  George.     Article  "Sous-claviere,"  Diet.  Jaccoud,  V.  xxxiii.,  1882. 

5.  Bergmann.    Die  Schussverletzungen  und  unterbindung  der  subclavia,  St.  Petersb 
med.  Woch.,  1877.     II.  99-200. 

6.  Bramann,  (F.).     "Das  Arteriell-venose  Aneurysma,"  Archiv  f.   klin.  Chir.,  Bed. 
1886,  xxxiii.  1-107. 

7.  Souchon,  E.     Operative  Treatment  of  Aneurisms  of  the  Third  Portion  of  the  Sub 
clavian  Artery,  .'\nnals  of  Surgery,  vol.  xxx.,  1895. 

8.  Delbet,  P.     Traite  de  Chirurgie  Clinique  et  operatoire.     Le  Dentu-Delbet,  V.  iv. 
1897.     (Maladies  chirurgicales  des  arteres.) 

9.  Bergmann-Bruns-Mickulicz(Chirur.  desHalses,  etc.),  Handbuchder  Prakt.Chirurg 
Bd.  ii.,  1900. 


282 


MATAS, 


Tabulated  Statement  of  Seventeen  Eecoeded  Cases  of 

Gathered  from  the 


No. 

Operator  or 
reporter. 

Sex 
and 
age. 

Nature 
of  in- 
jury. 

Seat  of  in- 
jury. 

Result. 

Primary 
hemor- 
rhage 

(syncope) 

Second- 
ary hem- 
orrhage. 

Associate 
or  compli- 
cating 
injury. 

Date  of 
appear- 
ance of 
aneuris- 
mal  signs 

1 
2 

Larrey,  D.  J.» 
Paris. 

Sanson.a 
Paris. 

M. 
32 

M. 

50 

Sabre 

Gun- 
shot 

Left  supra- 
clavicular, 
presumably 
3d  portion. 
Left  supra- 
clavicular. 

Recov- 
eiy. 

Recov- 
ery. 

"  Fright- 
ful hem- 
orrhage," 
(syncope) 

None. 

None 
recorded. 

Brachial 
plexus. 

9 

24  houTS. 
"  Next 
day." 

3 

B6rard,3 
Paris. 

M. 
adult 

Stab 

Right  supra- 
clavicular. 

Recov- 
ery. 

"  Not 
very 

Few  days 

copious." 

4 

Wattmann,* 
Vienna. 

M. 
22  (?) 
at  in- 
jury. 

Gun- 
shot 

Upper  arm 

and  shoulder 

(subclavio- 

axillary). 

Died. 

Post-ope- 
rative 

22  days 
after 

ligation. 

31  years. 

5 

Wederstrandt, 

J.  P.  C.8 
New  Orleans. 

Smith.  R.W.6 
Dublin. 

M. 

adult 

M. 

m'dle 

age 

Gun- 
shot 

Stab 

Right  sub- 
clavian, 2d 
or  3d  div. 

Left  supra- 
clavicular 
region  (2d 
division). 

Recov- 
ery. 

Recov- 
ery. 

"  Vio- 
lent." 

"Pro- 
fuse." 

None. 
None. 

Internal 
jugular 
vein  in 

addition  to 

subclavian; 

brachial 

plexus. 

6 

3  weeks. 

7 

Fisher,  G.'' 
Giittingen 

M. 
32 

Stab 

Clavicular 
region. 

Recov- 
ery. 

None. 

6th  day. 

8 

Letenneur.s 
Nantes. 

M. 
15 

Gun- 
shot 

Right  side  of 
neck,  prob- 
ably involv. 
Istdivision 
subclavian. 

Recov- 
ery. 

Little. 

None. 

Suspected 

brachial 

plexus,  jug. 

vein  close 

to  subclav. 

junction. 

Pleura 

opened  and 

septic 

haemo- 

thorax. 

Noticed 
next  day. 

9 

Will.  J.  C.  0.9 
Glasgow. 

M. 
adult 

Stab 

Left  subcla- 
vian vessels, 
3d  division. 

Died. 

Profuse. 

12th  day. 
13th  " 
19th  " 

20th  " 

12th  day 
tumor 
found. 

10 

Kirsch,  B.io 
Breslau. 

M. 

27 

Gun- 
shot 

Right  supra- 
clav.  tumor 
in  delto-pec- 
toral  groove 
near  clavicle 
(3d  division). 

Recov- 
ery. 

None. 

Possibly 
brachial 
plexus  in- 
jured. 

4th  dav 

1  Cliniques  Chir.,  Paris,  1829,  T.  iii.  p.  115. 

2  Reported  by  Robert  in  These  de  Concours,  Paris,  1842  (Des  Auevrismcs  de  la  region  Susclaviculaire). 
■s  Bull,  de  Soc.  de  Chir.  de  Paris,  1S65,  2  v.  18G6,  p.  367  et  seq.    Quoted  by  Richet  in  discussion  of 

Letenneur's  case. 

■>  Abstracted  from  Bericht  (iber  die  Deutsch  Natur  und  aerzt.  21  meeting,  1843,  Gratz,  1845.    Also 
reported  by  Rokitansky,  Ueber  die  einige  der  wichtigsten  kraukheiten  der  arterien,  Wien,  1852.; 

'"  New  Orleans  Medical  News  and  Hospital  Gazette,  1854-55,  vol.  i.  pp.  393-395. 


TRAUMATIC    A  RT  E  K  I  0-V  EN  O  US    ANEURISMS. 


283 


Arterio-venous  Aneurisms  of  the  Subclavian  Vessels. 
Literature  (1827-1901). 


Immediate  { 

effect  of     Non-opera-  Operation,  if  any ;  date 

injury        tive  treat-  and  indication  for 

on  arm.    |      ment.  operation. 


Distant  or  remote 
effects  of  aneur- 
ism on  arm. 


Arm  icy,   |  Pressure, 
pulseless,  •        ice, 
colorless,      repeated 
venesect'n. 


None. 


None  for 
primary 
injury. 


No  operation. 


Atrophy,  paralysis 

of  hand  ;  perma- 

I  nent  obliteration 

of  pulse  in  all  arm. 


Remarks. 


Double  ligature  third       After  lig.  arrested 
portion    on    17th    day     pulsation  in  arm  ; 
foraggravationof  pain  ,    returned  second 
and  vascular  disturb-   day ;  infection  ten 
ances.  j     days  after,  and 

secondary  hemor- 
rhage.   . 


None. 


Enlarged 

veins, 

diminished 

pulsation; 

arrest  of 
circulation 
on  elevat'n 

of  arm. 


;    Notable 
swelling  of 
arm.  diffi- 
cult deglu- 
i     titiou. 


None  re- 
corded. 


Boyer's 
compressor 
without 
effect. 
Rest,  diet, 
wet  com- 
presses 
(arnica), 
ice-bags. 


Compresses   Three  weeks  after  injury 
perchloride     operation  attempted, 
of  iron  and      but  patient  succumbed 
glycerin,       at  first  incision, 
pressure, 
opium, 
ice,  rest. 
Instrumen-   None, 
tal  com- 
pression ; 
not  im- 
proved. 


Withered,  paral- 
yzed, cold  ;  no 
sensation ;  pulse 
weaker  and  not 

synchronous 
with  other  side. 

Arm  cold,  oedema- 

tous,  and  pulseless; 

sloughing  of  little 

and  ring  fingers 

and  inner  side  of 

dorsum  and  palm 

to  ulnocarpal 

articulation. 


Pain  in  shoulder 
and  elbow. 


Persistence  of  aneurismal 
signs  for  more  than  10  years, 
for  which  patient  consulted 
Sanson  in  1832. 

Discharged  "several"  weeks 
later  with  persistence  of 
aneurismal  signs,  clamoring 
for  operation,  which  Bcrard 
and  Dietfenbach  refused. 

Immediate  eflfects  of  primary 
injury  not  recorded  ;  appar- 
ently insignificant;  aneur- 
ismal signs  and  tumor  re- 
quiring ligature  31  yrs.  after 
primary  injury:  arterio-ven- 
ous aneurism  confirmed  by 
autopsy. 

Died  of  diarrhoea,  1854,  7  yrs. 
after  injury,  and  with  per- 
sistent aneurismal  symp- 
toms ;  arterio-venous  aneur- 
ism confirmed  by  autopsy. 


About  7  mos.  after  injury 
sloughing  of  hand  occurred 
spontaneously,  slough  de- 
taching without  constitu- 
tional symptoms ;  tumor  at 
site  of  wound  size  of  walnut; 
stationary. 

Came  under  observation  1  yr. 
after  accident,  with  active 
aneurismal  signs,  and  was 
discharged  unimproved. 

Wound  healed  and  patient 
took  his  first  promenade  on 
21st  day  :  after  this  no  his- 
tory can  be  obtained. 


External  wound  had  healed 
already  when  first  second- 
ary hemorrhage  occurred. 
Autop.sy    revealed    arterio- 
venous nature  of  injury. 


Partial  paralysis 

fourth  and  fifth 

fingers. 


Came  under  observation  2^ 
months  after  injury  and  was 
discharged  unimproved  in 
any  respect. 


Arm  paral- 
yzed, anaes- 
thesia of 
fingers, 
skin  cya- 
nosed. 

8  Proceedings  Pathological  Society,  Dublin,  1860-61,  vol.  i.  part  3,  p.  158. 

^  In  mittheilungen  aus  der  chir.  Klinik.  Giittingen,  1861  (quoted  in  Bramann's  table— Das 
arteriell-veniise  aneurysma).    Archiv  f.  klin.  Chirurg.,  Langenbeck,  Berlin,  1886,  vol.  xxxiii.  p.  12. 

*  Bull.  Soc.  de  Chir.  de  Paris,  1865,  second  series,  1866,  p.  867. 

'  Glasgow  Medical  Journal,  Glasgow,  1875,  vol.  vii.  p.  173. 

1"  Ueber  traumat.  aneurysm,  Breslau,  1875.  Thesis  quoted  by  Bramann  in  "  Das  arteriell-venose 
aneurysma."    Archiv  f.  klin.  Chirurg,,  von  Langenbeck,  Berlin,  1886,  vol.  xxxiii.  p.  12. 


284 


MATAS. 


Tabulated  Statement  of  Sevexteex  Recorded  Cases  of 

Gathered  from  the 


Primary 

Associate 

Date  of 

Operator  or 

Sex 

Nature 

Seat  of  in- 

hemor- 

Second- 

or compli- 

appear- 
ance of 

No. 

reporter. 

and 

of  in- 

jury. 

Result      rhage 

ary  hem- 

cating 

age. 

jury. 

(syncope) 

orrhage. 

injury. 

aneuris- 
mal  signs 

11 

Arango, 
A.  P.," 

M. 

27 

Stab 

Posterior 
region  of 

Recov-  "  Abund- 
ery.      ant,  con- 

None. 

8th  day. 

Medellin, 

shoulder 

trolled  by 

Spain. 

(3d  division). 

patient's 
hand." 

12 

Von  Rotter, 

M. 

Stab    !  Left  infra- 

Recov-    Pouring 

9  days 

Nerve  (not 

Discov- 

G.12 

•2S 

clavicular 

ery.          in  a 

after 

deflnitelv 

ered  next 

Berlin. 

(3d  division). 

stream 
(syncope) 

injury 
(mid- 
night). 

stated)." 

day. 

13 

Wedekind.is 

M. 

Stab      Left  sub- 

Recov-   Profuse, 

None. 

None. 

5  days. 

(Jeorge, 

32 

clavian  be- 

ery.       no  syn- 

Berlin. 

low  middle 

of  clavicle. 

(3d  division). 

cope, 

easily 

control' d. 

14 

Veiel.i* 

M. 

Stab 

Right  infra- 

Recov-   Profuse. 

3  days 

None. 

Noticed 

Cannstadt. 

23 

clavicular 
(3d  division). 

ery. 

afte"r 
injury 

(mid- 
night). 

on  9th 
day. 

15 

Matas,  R.15 

M. 

Revol- 

2d division 

Recov- 

Large 

None. 

Brachial 

4  hours 

New  Orleans. 

24 

ver,  38   of  subclavian 

ery,        hsema- 

plexus ; 

after  in- 

calibre   through  the 

1     toma, 

paralysis 

jury. 

ant.  scalene. 

external 
hemor- 
rhage 

of  arm. 

1  moderate 

no  syn- 

cope. 

16 

Vallas.i« 

M. 

Frac- 

Supra-clav- 

Death.     Hsema- 

None. 

Internal 

10th  day 

Lyons,  1900 

25 

ture  of  icular  '2d  and 

toma 

jugular 

recog- 

clavicle   1st  division 

formed 

vein  with 

nized. 

(indi-  ,  (right  side). 

immedi- 

subclavian 

rect). 

ately. 

vessels. 

17 

Reboul,'- 

M. 

Frac- 

Aneurisnial 

Death. 

Aneur- 

None. 

Tubercu- 

8th day 

Montpellier, 

30 

ture  of  '  hsematoma 

ismal 

losis  of 

after  in- 

France, 1891 

left        enormous, 

tumor 

lungs  and 

jury  : 

clavicle  filling  supra- 

;  probably 

of  iierito- 

aneurism 

(indi-      clavicular 

I     began 

neum  ; 

p'sitively 

rect).      region  and 

9  days 

marked 

develop'd 

whole  left 

after  in- 

cachexia 

35  days 

side  of 

jury. 

and  maras- 

after 

• 

|hack  &  chest. 

mus. 

injury. 

1'  Bull,  et  M(5m.  Soc.  de  Chir..  Paris,  1880,  vol.  vi.  pp.  60  and  70,  and  An.  de  I'Acad.  de  Med.  de 
Medellin.    Medellin,  Spain,  1892  xv.  pp.  55-57.     Abstracted  from  Spanish  text,  1892. 

'-  Ueber  die  Stichverletzungen  der  Schlusselbeingefass,  Berlin,  klin.  Wochenschrift,  1893,  vol. 
XXX.  pp.  278-284. 

13  Deutsch  med.  Wochen.,  Leipzig,  1895,  vol.  vii.  p.  53. 


TRAUMATIC    A  RT  E  R  I  0-V  ENO  US    ANEURISMS. 


285 


Arterio-venous  Aneurisms  of  the  Subclavian  Vessels. 
Literature  (1827-1901). 


Immediate  i 

effect  of  Non-opera-    Operation,  if  any  ;  date  Distant  or  remote 

injury  live  treat-  1       and  indications  for  effects  of  aneur- 

on  arm.          ment.      i              operation.  ism  on  arm. 


Remarks. 


Swollen, 

Compres- 

cold. 

sion;  band- 

purple, 

ages  to 

pulseless, 

arm. 

medius. 

ring,  and 

I'tle  fingers 

paralyzed. 

Pulse  weak 

Wound 

and 

packed 

retarded. 

with 

cyanosis, 

iodoform 

enlarged 

gauze. 

veins,  etc. 

Pulse 

Antiseptic 

weaker. 

dressings 

to  wound. 

After 

Antiseptic 

injury 

dressings. 

radial 

pulse 

retained. 

None. 


On  9th  day  (midnight) 
clavicle  resected;  artery 
ligated  on  outer  side  of 
scalenus,  subclavian 
and  other  veins  ligated; 
wound  allowed  to  heal 
by  granulation. 

No  operation. 


Q2dema  of  arm  ;  JTen  years  after  operation  pa- 
varicose  veins  of  i  tient  was  reported  by  friends 
arm.  in  almost  perfect  health. 


Arm  cold  and 
pulseless  during 
operation ;  pulse 
did  not  return. 


Arm  feels  numb  ; 

tingles  when 
allowed  to  hang. 


Pulse  lost    Gauze  com- 
immedi-       press  and 
ately,  re-   i    adhesive 
turned  5th  |     plaster, 
day.  ice-bags. 


Arm 

motionless 

from 
fracture. 


On  9th  day  artery  ligated 
outside  of  scalenus;  ax- 
illary artery  ligated  be- 
yond wound  ;  both  ax- 
illary  veins    tied   and 
venous  branch  from 
scapula  ligated  ;  clot 
turned  out  of  sac  and 
wound  packed 

On  9th  day.  Sept.  13, 1900, 
subclavian  ligated  on 
both  sides  of  scalene  ; 
lateral  suture  of  vein  ; 
osteoplastic  resection 
of  clavicle,  provisional 
traction  loop  around 
anomalous  subclavian 
first  portion  ;  wound 
healed  per  primam. 

Operation  for  suppura- 
tion in  sac,  Sept.  22, 1900;| 
resection  of  clavicle  ;j 
prophylactic  ligature  ofi 
subclavian  artery  impos- 
sible; free  incision  into 
sac;  frightful  hemor-; 
rhage  controlled  by  7! 
forcejjs  left  in  sUu ; ! 
wound  packed.  ' 


Bandage    No  operation  attempted, 

for  patient  too  weak, 

fracture, 


Immediately  after 

operat'n  arm  white 

and  cold ;  veins 

thrombosed,  arm 

blue  and  hand 

swollen;  sensibility 

impaired ;  thermic 

sense  lost ;  arm 

diminished  in  size. 

Sloughing  of 

thumb  and  little 

finger,  part  of 
hand  and  forearm. 


Gelatin 
injection, 
immobil- 
ization 
bandage. 


Discharged  a  few  weeks  after 
operation  healed  ;  resumed 
occupation  as  a  stone-cutter; 
no  gangrene  or  disability  of 
extremity  reported. 


7  mos.  after  injury  all  signs  of 
aneurism  persist,  but  suffers 
no  inconvenience,  and  fol- 
lows regular  occupation 
(locksmith). 

Last  report  ^3^  mos.  after  in- 
jury ;  marked  disability  of 
arm  and  hand  ;  trophic  and 
vascular  changes  marked. 


Last  report  July  1,  1901  ;  pa- 
tient in  robusthealth  ;  right 
hand  and  forearm  perma- 
nently disabled. 


Death  four  hours  after  opera- 
tion from  surgical  anaemia 
and  shock.  Autopsy  :  non- 
union of  fracture;  internal 
jugular  and  subclavian 
veins  torn  by  distal  frag- 
ment, subclavian  artery  per- 
forated also;  scalenus  anti- 
cus  torn  from  attachments. 


Death  five  days  after  admis- 
sion to  hospital  while  en 
route  to  his  home;  aneur- 
ismal  ha'raatoma  enormous, 
filled  entire  supraclavicu- 
lar space  front  of  chest  and 
back,  displacing  scapula. 


'<  Medicinische  Correspondenz-blatt  des  Wurtemburg  aerzte  landsverein,  Stuttgart,  1895,  vol. 
xlv.  p.  123. 

'■'  Transactions  OF  THR  American  Surgical  Association,  1901. 

'«  Reported  by  Galiois  and  PioUet,  Rev  de  Chirurg.,  Paris,  .July  10,  1001,  No.  7,  pp.  2;i-30. 

1"  Reported  by  T.  Fabre.  Thesis,  Montpellier,  1894  ;  and  Galiois  and  Piollet,  Rev.  de  Chirurg. 
July  10,  1901. 


286  MATAS, 


APPENDIX. 

Two    Additional    Cases     of     Traumatic     Arterio-Venous 

Aneurisms   of   the   Subclavian   Vessels,  and    One 

of  Injury  of  Both  Vessels,  Not  Included 

IN  the  Text. 


Case  I.  Arterio-venous  afieurism  of  the  right  subclavian  artery  and 
of  the  subclavian  and  internal  jugtdar  veins,  caused  by  indirect  fracture 
of  the  clavicle  ;  operation;  death. — Operator,  Dr.  Vallas,  Hotel  Dieu, 
Lyons.  Reported  by  MM.  Gallois  and  Piollet,  Revue  de  Chirurgie, 
Paris,  July  lo,  1901  :   2ime  Annee,  pp.  23-30. 

A.  F.,  aged  twenty-five  years  ;  farmer;  good  antecedent  history,  but 
weak  constitution;  small  stature  and  spare  build;  habitually  pale. 
On  July  2,  1900,  while  riding  a  mule  the  patient  was  suddenly  thrown 
to  the  ground.  He  first  fell  on  his  feet,  and  then  on  his  right 
shoulder.  He  felt  an  acute  pain  in  the  shoulder,  but  picked  himself 
up  and  led  the  mule  back  to  his  stable.  In  doing  this  he  had  to  walk 
up  an  inclined  road  by  a  hillside  for  twenty  minutes.  While  on  his 
way  home  he  became  conscious  of  the  formation  of  a  large  swelling 
at  the  root  of  the  neck  on  the  right  side.  This  swelling  increased 
rapidly,  and  by  the  time  he  reached  his  house  it  had  reached  the  ear 
and  projected  beyond  it.  As  he  walked  he  became  short-winded,  and 
when  he  arrived  at  the  house  he  was  completely  exhausted.  He  could 
not  stand  on  his  feet,  and  had  to  go  to  bed  at  once.  A  physician 
who  was  summoned  detected  a  fracture  of  the  clavicle,  with  consider- 
able subcutaneous  emphysema.  In  the  days  that  followed  the  swell- 
ing rapidly  diminished,  while  a  very  considerable  ecchymosis  spread 
from  the  neck  to  the  corresponding  side  of  the  chest. 

When  on  the  tenth  day  the  bandages  were  removed  a  persistent  but 
almost  painless  tumor  had  formed  immediately  above  the  clavicle  and 
outside  of  the  sternomastoid  muscle.  As  this  tumor  remained  the 
patient  consulted  other  physicians  at  Grasse,  who  diagnosed  an  aneu- 
rism of  the  subclavian  artery,  caused  by  fracture  of  the  clavicle.  On 
September  9th  (about  sixty-two  days  after  the  accident)  a  gelatin 
serum  injection,  prepared  by  Lancereaux's  method,  was  administered. 


TRAUMATIC    A  RT  ER  I  0-VEN  O  US    ANEURISMS.  28/ 

The  patient  was  then  advised  to  enter  Professor  OUier's  clinic  at 
the  Hotel  Dieu,  Lyons,  where  he  was  admitted  Septennber  19th. 
Condition  on  admission  :  The  supraclavicular  fossa  is  filled  with  a 
mass  as  large  as  a  fist,  which  extends  from  the  outer  edge  of  the 
clavicular  attachment  of  the  sternomastoid  to  the  outer  third  of  the 
clavicle.  The  tumor  is  globular  in  shape,  but  irregular  in  contour. 
The  upper  outline  of  the  tumor  can  be  felt  four  fingers'  breadth  above 
the  clavicle.  It  is  most  prominent  about  the  level  of  the  fracture, 
which  is  situated  at  the  junction  of  the  outer  with  the  middle  third  of  this 
bone.  There  is  a  complete  failure  of  osseous  union  ;  the  fragments  are 
movable.  The  inner  fragment  projects  under  the  skin  anteriorly.  The 
outer  or  acromial  fragment  is  driven  inward  and  backward,  but  appears 
to  be  outside  the  anterior  scalene.  The  patient  can  scarcely  move  his 
arm,  which  hangs  motionless  by  his  chest.  All  the  signs  of  aneurism 
are  recognizable  in  the  tumor,  except  that  there  is  no  thrill.  There  is 
a  distinct  systolic  murmur  and  expansile  pulsation.  Pulse,  100,  can 
be  distinctly  felt  at  both  wrists,  though  weakeron  the  right  side.  The 
right  carotid  can  he  outlined  along  the  inner  side  of  the  sterno- 
mastoid. No  pleural  or  pulmonary  lesions.  No  apparent  lesion  of 
brachial  plexus.  A  swelling  still  remains  at  the  seat  of  the  gelatin 
injection.  On  September  20th  the  patient  complains  of  pain  in  the 
aneurism.  He  has  fever.  Temperature,  38.8  C.  ;  pulse,  108.  The 
swelling,  indicating  seat  of  gelatin  injection,  is  also  tender  and 
inflamed. 

On  September  21st  the  tumor  increases  rapidly  in  size;  the  over- 
lying skin  is  red,  oedematous,  and  inflamed.  The  seat  of  gelatin 
injection  is  also  evidently  inflamed  and  infected. 

In  the  absence  of  Professor  Oilier,  Mr.  Vallas  takes  charge  of  the 
case  and  diagnosticates  "an  inflamed  aneurismal  haematoma,  with 
threatened  suppuration  of  the  sac  and  general  septic  infection."  It 
is  decided  that  an  operation  is  urgently  indicated,  and  Mr.  Vallas 
operates  September  2 2d,  1900.  Ether  anaesthesia.  A  horizontal  in- 
cision is  made  parallel  with  and  one  finger's  breadth  above  the  clav- 
icle ;  this  is  joined  by  a  vertical  incision  following  the  inner  edge  of  the 
sternomastoid  down  to  the  sternum.  The  insertion  of  the  sterno- 
mastoid is  divided  and  reflected  upward  together  with  the  cutaneous 
flap.  The  omohyoid  is  divided  in  the  middle,  and  each  end  is  re- 
tracted. The  sac  is  now  exposed.  In  order  to  expose  the  subclavian, 
which  is  hidden  by  the  tumor,  the  whole  inner  fragment  from  the  line 
of  fracture  to  the  sternoclavicular  joint  is  disarticulated  and  excised. 


288  MAT  AS, 

Notwithstanding  the  great  exposure  of  the  field  obtained  by  this 
procedure,  it  is  still  difficult  to  recognize  and  isolate  the  subclavian 
artery.  The  trunk  of  this  vessel  is  hidden  by  the  sac  and  the  large 
trunk  of  the  right  innominate  vein.  At  this  juncture,  while  explor- 
ing for  the  artery  with  a  grooved  director,  a  discharge  of  about  a 
tablespoonful  of  thick,  reddish  pus  takes  place,  and  the  director  pene- 
trates into  the  cavity  of  the  sac.  At  the  same  time  a  large  clot  appears 
and  obliterates  the  opening  made  in  the  sac.  In  view  of  the  difficulty 
of  applying  a  prophylactic  ligature  upon  the  subclavian  artery  at  its 
origin,  M.  Vallas  decided  to  make  a  large  free  opening  into  the  sac, 
with  the  view  of  securing  the  injured  and  bleeding  vessels  in  situ. 
The  instant  this  is  done  a  flood  of  mixed  blood  and  clots  deluges  the 
field,  the  hemorrhage  coming  simultaneously  from  many  points.  In 
spite  of  a  vigorous  tamponade  of  the  sac,  the  blood  continues  to 
flow.  It  appears  to  come  most  vigorously  from  the  upper  and  inner 
angle  of  the  wound.  The  cutaneous  incision  is  quickly  enlarged,  and 
while  the  assistants  are  making  vigorous  compression  at  the  bottom  of 
the  sac,  the  operator  succeeds  with  much  difficulty  in  placing  two 
forceps  on  the  internal  jugular,  one  within  and  the  other  outside  the 
sac.  This  stops  the  bleeding  at  this  point.  On  removing  the  gauze 
packs  the  hemorrhage  instantly  recurs,  pouring  from  several  orifices. 
After  great  difficulties  and  much  loss  of  blood,  the  bleeding  is  finally 
controlled  by  a  series  of  forceps  applied  to  the  chief  bleeding-points. 

In  the  meantime  the  patient  grows  very  weak,  and  500  grammes  of 
saline  solution  are  injected  and  other  restoratives  are  applied.  The 
wound  is  packed  with  iodoform  gauze,  leaving  seven  clamps  in  situ. 
The  patient  is  then  put  to  bed,  but  in  spite  of  the  additional  injection 
of  500  grammes  of  saline  solution  death  takes  place  four  hours  after  the 
operation. 

Autopsy.  A  very  oblique  fracture  of  the  clavicle  is  recognized,  the 
sharp  edge  of  the  outer  fragment  projecting  four  centimetres  beyond  the 
line  of  fracture.  The  scalenus  anticus  is  almost  completely  torn  from 
its  attachment  to  the  first  rib.  The  internal  jugular  vein  is  opened 
longitudinally  by  a  tear  two  centimetres  in  length.  The  subclavian 
vein  had  been  almost  completely  torn  across,  and  its  walls  were  incor- 
porated in  the  sac. 

The  subclavian  artery  showed  a  small  perforation  which  communi- 
cated with  the  sac.  The  tear  in  the  artery  had  taken  place  a  short  dis- 
tance from  the  thyroid  axis.  The  internal  jugular  was  also  opened 
and  freely  communicated  with  the  sac.     The  distal  fragment  had, 


TRAUMATIC    A  RTE  K  I  0-V  ENO  US    ANEURISMS.  289 

therefore,  been  driven  into  the  neck,  tearing  the  scalenus  anticus  and 
penetrating  the  subclavian  and  internal  jugular  veins  and  the  middle 
third  of  the  subclavian  artery. 

Case  II.  Arierio-venous  aneurism  (^probably  of  the  subclavian  artery 
and  veiii)  caused  by  indirect  fracture  of  the  clavicle ;  no  operation  ; 
death. — Service  of  D.  Reboul,  Montpellier,  France.  Originally  re- 
ported by  Th.  Fabre.  These,  Montpellier,  1894,  and  abstracted  from 
Gallois  and  PioUet's  article,  loc.  q\\..,  Revue  de  Chirurgie,  No.  7,  July 
10,  1901. 

J.  A.,  aged  thirty  years ;  locksmith.  Fell  from  a  carriage  March 
4,  1894,  and  struck  left  shoulder.  The  clavicle  was  fractured  at  the 
junction  of  the  outer  and  middle  third.  The  fracture  was  set  with 
immobilizing  bandages.  Eight  days  after  the  accident  the  patient 
removed  the  bandages  and  tried  to  use  his  arm.  While  moving  the 
arm  he  felt  a  sharp  pain  at  the  seat  of  fracture,  which  radiated  to  the 
dorsal  surface  of  the  forearm  and  hand.  On  March  31st  (nineteen 
days  after  this  occurrence)  another  sharp  pain  was  felt  by  the  patient, 
and  a  tumor  was  felt  in  the  supraclavicular  space  on  a  level  with  the 
fracture.  On  April  8th  the  patient  was  seized  with  a  violent  cough, 
and  the  swelling  greatly  increased  in  size,  and  became  most  painful. 
A  traumatic  aneurism  was  then  recognized  by  the  attending  physician. 
On  April  loth  he  was  seen  by  Dr.  Reboul,  who  confirmed  the  diag- 
nosis. All  the  signs  of  aneurism  existed,  including  a  marked  thrill 
and  signs  of  venous  disturbance.  The  tumor  extends  over  the  left 
thoracic  region  and  covers  an  immense  area.  It  extends  five  centi- 
metres below  the  nipple,  fills  the  axilla,  and  descends  to  the  ninth 
rib;  it  projects  posteriorly  in  the  dorsal  region,  where  it  lifts  the 
scapula  and  displaces  it  outward,  and  can  be  felt  transversely,  touch- 
ing the  vertebral  column  downward  to  the  tenth  rib.  The  entire 
supraclavicular  space  is  filled  by  it,  the  penetrating  hsematoma,  up  to 
the  posterior  border  of  the  scalenus.  The  veins  are  turgid  and  ob- 
structed. The  left  arm  is  powerless.  Marked  trophic  disturbances 
exist  in  the  arm,  showing  lesion  of  the  brachial  plexus.  The  pulse 
in  the  left  brachial  and  radial  arteries  is  scarcely  perceptible.  In 
addition  to  this  great  vascular  disturbance,  the  patient  gives  evidence 
of  advanced  pulmonary  tuberculosis  and  of  chronic  peritonitis.  In 
view  of  all  these  complicating  and  hopeless  conditions,  and  the  very 
bad  state  of  the  patient,  which  would  not  even  justify  the  administra- 
tion of  an  ancesthetic,  Dr.  Reboul  decides  not  to  interfere.  Five 
days  after  his  admission  to  the  hospital  the  relatives  of  the  patient 

Am  Surg  ig 


290  MATAS, 

decided  to  take  him  to  his  village.     He  died  en  route,  and  no  post- 
mortem was  held. 

Note. — Gallois  and  Piollet,  after  a  careful  consideration  of  this 
case,  believe  that  it  should  be  classified  as  an  arterio-venous  aneurism, 
as  all  the  signs  pointed  to  a  lesion  of  both  artery  and  vein. 

[In  Gallois  and  Piollet's  very  interesting  contribution,  ten  obser- 
vations are  summarized  from  the  literature,  which  illustrate  the  dan- 
gers of  closed  (simple)  fractures  of  the  clavicle  from  the  stand-point  of 
complicating  lesions  of  the  subclavian  vessels.  In  only  two  of  these 
ten  cases  were  both  vessels  (artery  and  vein)  implicated,  and  these  are 
so  rare  and  instructive  that  they  are  worthy  of  special  and  full  men- 
tion in  connection  with  the  subject  of  this  paper, — R.  M.] 

Case  III.  Vasilyeff  (M.  A.)  Subclavian  artery  and  vein  tied 
under  the  clavicle  for  hemorrhage  in  abscess  cavity. —  Chir.  Vestnik, 
1886,  II.  431-436.     (Surgical  Clinic  of  Prof.  J.  A.  Yefremowski.) 

M.  L.,  female,  aged  twenty  years,  entered  clinic  November  21,  18S4. 
Patient  first  felt  pain  caused  by  an  abscess  (?)  two  weeks  previously. 
Tumor  was  found  in  right  axilla,  which  increased  until  the  29th,  when 
it  occupied  the  subclavian  and  axillary  regions.  December  ist,  under 
chloroform;  incision  made  by  Vasilyeff  in  axillary  line,  much  pus 
issued  ;  finger  inserted  in  abcess  cavity  ascended  to  middle  of  clavicle  ; 
wound  enlarged  and  drainage  inserted ;  great  hemorrhage  occurred, 
stopped  by  grasping  bleeding-points  en  masse  with  haemostatic  forceps 
and  left  in  place.  December  3d,  dressing  changed.  Much  bleeding 
at  night.  December  4th,  pulse,  104;  temperature,  38.6°  C.  Profes- 
sor Yefremowski,  under  chloroform,  enlarged  wound,  sought  cause  of 
hemorrhage  ;  on  removal  of  forceps,  hemorrhage  great  and  subclavian 
artery  was  then  tied  ;  hemorrhage  stopped  a  while,  then  began  again, 
and  was  venous ;  subclavian  vein  was  then  tied.  Wound  was  disin- 
fected, packed  and  bandaged ;  patient  put  to  bed  ;  hot  bottles  around 
arm.  Profuse  sweating  at  night.  Pulse  in  left  hand,  100  ;  tempera- 
ture, 39.3°  C.  December  6th  to  20th,  daily  change  of  dressing. 
Temperature  varied,  38^^  C.  morning  to  39°  C.  night  and  more. 
Pulse  in  radial  artery  of  operated  arm  not  found  ;  oedema  of  arm  in 
spite  of  flannel  bandage  with  pressure.  December  14th  ligature  slipped 
from  artery.  Small  abscesses  in  little  finger  and  palm  \  opened  and 
changed  on  alternate  days ;  wound  healed  by  granulation  ;  oedema ; 
tumor  in  region  of  external  middle  of  humerus  ;  acute  osteomyelitis  of 


TRAUMATIC    A  R  TER  I  O-VEN  O  US    ANEURISMS.  29 1 

humerus ;  two  counter  openings  made  and  drains  inserted  intero- 
externally.  March  ist,  erysipelas  in  the  arm  and  chest ;  wound 
healed  the  middle  of  the  month.  Wound  healed;  function  of  arm 
limited  ;  right  arm  thinner  than  the  left.  Movement  in  shoulder  and 
elbow-joints  impossible.  Massage,  active  and  passive  movements. 
Electricity. 

June  i6th.  Left  hospital.  Movement  in  the  shoulder-joint ;  almost 
re-established  in  elbow;  in  phalangeal,  metacarpal  joints,  flexor  move- 
ments imperfect ;  no  pulse  in  right  radial  artery. 

Patient  was  seen  in  fall  of  1885  ;  improvement;  does  hard  work; 
no  radial  pulse,  but  right  arm  thinner  than  left. 

[Note. — This  case  is  properly  not  one  of  arterio- venous  aneurism  of 
the  subclavian  vessels,  but  simply  illustrates  the  dangers  of  hemorrhage 
and  infection  following  a  secondary  ulceration  of  these  vessels  when 
exposed  in  a  suppurating  cavity.  As  this  observation,  originally  pub- 
lished in  a  Russian  journal,  is  difficult  of  access,  it  is  here  reproduced 
for  the  benefit  of  other  students  of  the  literature  of  the  subject  who 
may  be  interested  in  the  nature  of  the  case  in  consulting  the  bibli- 
ography.— R.  M.] 


292  DISCUSSION, 


DISCUSSION. 

Dr.  Arthur  Dean  Bevan,  of  Chicago. 

I  am  sorry  that  the  duties  of  the  Nominating  Committee  have  pre- 
vented me  from  hearing  the  paper  of  Dr.  Matas,  but  he  sent  me  a 
synopsis,  and  I  have  a  very  brief  discussion  to  present  after  reading  it. 
The  case  reported  by  Dr.  Matas  represents  such  a  rare  condition,  the 
histories  of  the  few  similar  cases  have  been  so  thoroughly  reviewed, 
and  the  surgical  procedures  adopted  by  him  have  been  so  well  planned, 
that  there  is  little  room  for  criticism.  I  have  not  handled  a  similar 
case,  but  have  studied  this  field  somewhat  in  a  case  of  traumatic  aneu- 
rism of  the  carotid,  as  well  as  in  one  other  case.  The  point  which 
presented  itself  to  my  mind,  and  which  would  naturally  present  itself 
to  the  mind  of  a  surgeon  confronted  with  such  a  case,  in  addition  to 
the  facts  brought  out  by  Dr.  Matas,  was  the  possibility  of  suturing 
both  the  artery  and  vein  after  temporary  ligation  of  the  vessels.  My 
present  view  would  be  in  favor  of  Dr.  Matas'  plan  of  applying  a  suture 
to  the  vein  and  relying  upon  a  ligature  for  the  artery.  One  must  also 
remember  the  possibility  of  effecting  a  cure  by  proximal  and  distal 
ligation  of  the  artery  close  to  the  point  of  injury  without  ligating  the 
vein,  and  this  is  a  question  which  should  be  carefully  considered.  The 
great  desirability  is  to  include  as  small  a  part  of  the  artery  as  possible 
between  the  ligatures.  The  fear  of  secondary  hemorrhage  has  largely 
disappeared,  and  it  has  been  clinically  shown  that,  provided  primary 
healing  is  obtained,  there  is  little  ground  for  the  return  of  this  fear,  as 
is  shown  in  ligating  the  external  carotid.  In  regard  to  hemorrhage 
from  the  vertebral  artery,  this  is  to  be  expected  when  the  subclavian  is 
ligated  proximal  to  that  branch,  and  again  in  its  third  portion  ;  of 
course,  a  hemorrhage  from  the  vertebral  would  necessarily  take  place 
in  all  cases.  As  to  the  prognosis  without  operative  interference,  this 
is  a  very  interesting  point  in  connection  with  these  cases,  as  the  prog- 
nosis is  surprisingly  good  without  interference,  and  the  life-history  of 
these  cases  has  been  longer  without  interference  than  with  it.  Liga- 
ture of  an  arterio-venous  aneurism  of  the  carotid  gives  a  life- history 
of  from  twelve  to  twenty  years,  whereas  it  is  longer  in  the  non-oper- 
ated than  in  the  operated,  thus  making  the  question  of  operation.,  as 
has  recently  been  stated,  rather  a  relative  one. 

The  question  of  the  use  of  gelatin  in  these  cases  is  to  be  consid- 


TRAUMATIC    ARTERIO -VENOUS    ANEURISMS.  293 

ered.  Recently  a  colleague  of  mine  has  had  a  case  under  observa- 
tion which  he  presented  to  the  Chicago  Surgical  Society,  in  which  he 
believes  he  has  obtained  a  distinct  improvement  by  2  per  cent,  gelatin 
injections.  Of  course,  one  should  mention  the  treatment  by  digital 
compression. 

One  thing  interested  me  particularly  from  the  stand-point  of  the  sur- 
gical anatomy,  and  that  is  the  singular  fact  that  the  last  two  cases  of 
ligation  of  the  subclavian  vein  reported  in  the  literature  on  ligation 
the  operators  have  made  the  statement  that  they  were  cases  of  anoma- 
lous subclavian  artery.  They  were  both  on  the  right  side,  and  sprung 
directly  from  the  arch.  On  cannot  help  but  be  struck  with  this  fact, 
and  to  ask  for  an  interpretation.  Personally,  without  criticising  the 
observations  of  either  of  these  operators,  I  should  be  rather  inclined 
to  the  view  that  probably  in  both  cases  the  operators  were  surprised  at 
the  great  length  of  the  artery.  Post-mortems  would  possibly  have 
demonstrated  a  short  innominate.  That  would  be  one's  natural  con- 
clusion from  the  rather  great  rarity  of  this  anomalous  subclavian  coming 
direct  from  the  arch. 

Dr.  W.  S.  Halsted,  of  Baltimore. 

I  really  have  nothing  to  say  except  to  congratulate  Dr.  Matas  upon 
this  operation,  as  I  know  what  it  means  and  what  a  great  deal  of  nerve 
it  takes.  My  case  was  on  the  left  side,  and  I  ligated  the  first  portion 
of  the  subclavian. 

In  reference  to  the  cocaine  solution,  I  agree  with  Dr.  Matas  that  the 
principles  which  Schleich  has  emphasized,  and  which  I  emphasized 
before  him,  are  very  important  ones.  I  wish  to  say  a  word  in  refer- 
ence to  the  use  of  very  weak  solutions.  For  many  years  we  used  solu- 
tions that  had  scarcely  any  cocaine  in  them.  We  began  with  a  very 
weak  solution,  and  continued  with  water,  while  in  some  cases  we  used 
water  alone.  We  foimd  that  very  mild  solutions  of  cocaine  were  better 
than  water,  and  discovered  that  a  i  :  3000  or  i  :  5000  worked  satisfac- 
torily in  every  case.  For  ordinary  purposes  this  is  sufficient,  and 
patients  do  better  when  very  little  cocaine  is  used.  Their  power  of 
resistance  is  greater,  and  later  they  lose  their  inhibition,  which  is  one 
reason  for  using  mild  solutions.  I  recall  the  case  of  an  old  gentleman 
from  out  of  town  who  was  suffering  from  two  hernias  where  cocaine 
was  used  in  the  operation.  A  i  :  1000  solution  was  employed  for  the 
first  operation,  and  he  was  very  much  affected  by  the  cocaine,  although 
very  little  was  used.     For  the  first  twenty-four  hours  he  was  very  much 


294  DISCUSSION. 

depressed,  and  said  he  would  not  have  the  other  side  done.  We 
finally  persuaded  him  to  let  us  do  it,  which  we  did  with  a  very  mild 
solution  indeed.  He  had  no  bad  effects,  and  stood  the  operation  very 
much  better. 

My  first  publication  on  water  as  an  anaesthetic  is,  of  course,  remem- 
bered, and  in  the  two  articles  I  wrote  later  all  the  points  made  by 
Schleich  were  discussed. 

Dr.  Theodore  A.  McGraw,  of  Detroit. 

There  is  one  other  point  which  is  very  important  upon  which  I  would 
like  to  say  a  word.  The  prognosis  of  all  traumatic  aneurisms  is  a  very 
different  thing  from  the  prognosis  of  aneurisms  due  to  divided  artery. 
After  the  Civil  War  I  examined  for  pensions  for  many  years,  and  saw 
a  large  number  of  old  soldiers  with  aneurisms.  I  remember  one  man 
who  had  an  aneurism  of  the  carotid  artery  produced  by  a  gunshot 
wound.  Year  after  year  he  came  to  me  to  be  examined,  and  I  saw 
him  for  a  number  of  years  in  succession.  Another  man  had  a  blow 
in  the  femoral  artery,  which  lasted  twenty  years,  with  traumatic  aneu- 
rism. In  these  large  arteries  of  the  neck,  where  operations  are  ex- 
ceedingly dangerous,  this  point  should  be  taken  into  account. 

Dr.  Bevan.  In  regard  to  the  Dr.  Halsted  whom  I  mentioned  in 
my  discussion,  I  would  like  to  state  that  I  referred  to  the  Dr.  Halsted 
in  Chicago  as  the  man  who  had  recently  ligated  the  first  portion  of 
the  subclavian. 

Dr.  Matas.  The  points  presented  by  Dr.  Bevan  and  the  gentlemen 
who  have  followed  him  are  very  well  taken.  They  have  struck  the 
keynote  of  the  discussion  when  referring  to  the  prognosis.  I  have 
fully  discussed  this  plan  of  the  subject  in  my  paper,  but  the  limited 
time  at  my  disposal  prevented  me  from  referring  to  it  in  the  abstract. 

After  the  arterio-venous  anastomosis  has  been  fully  established,  the 
question.  Shall  we  operate  or  not?  is  a  very  serious  one.  In  ii  or  12 
cases  out  of  15  the  patient  recovered  from  the  immediate  effects  of  the 
injury  without  operation,  but  many  observations  fail  to  show  what 
became  of  the  patients  in  after  years.  In  several  of  these  the  subse- 
quent history  shows  that  the  lesion  persisted  with  evil  and  disastrous 
consequences ;  in  others  there  was  a  well-authenticated  survival  after 
a  long  interval  of  time  ;  but  in  all  but  two  of  the  unoperated  cases 
the  lesion  persisted  in  an  active  state  indefinitely  in  spite  of  the  treat- 


TRAUMATIC    A  RT  E  R  I  0-V  ENO  US    ANEURISMS.  295 

ment ;  in  several  it  is  apparent  that  the  lesion  was  simply  tolerated 
because  there  was  no  other  alternative  left  to  the  patient.  In  the 
majority  of  the  cases  it  cannot  be  denied  that  the  lesion  persists  as  an 
active  pathological  condition,  which,  while  compatible  with  a  long 
survival,  is  always  a  menace  to  the  health  and  life  of  the  patient.  It 
creates  a  weak  and  vulnerable  point  in  the  circulation.  The  interest- 
ing question  that  is  not  yet  decided  is,  Have  the  conditions  of  opera- 
tive surgery  progressed  sufficiently  to  justify  a  departure  from  the  old- 
established  rule  of  non-interference  .to  a  more  aggressive  policy? 
This  question  I  have  endeavored  to  answer  in  my  paper.  In  my  own 
case  I  departed,  against  my  inclinations,  from  the  old  classical  rule  of 
non-intervention,  chiefly  because  the  lesion  was  a  very  recent  one  and 
the  patient  could  not  remain  in  the  city  under  observation,  and  I  felt 
that  he  could  not  be  trusted  in  his  doubtful  condition  in  a  distant  set- 
tlement without  risk. 

While  I  am  much  gratified  at  the  result,  in  spite  of  the  unfortunate 
sloughing  of  a  part  of  the  extremity  (which  had  been  previously  par- 
alyzed by  the  injury)  the  case  fully  illustrates  the  difficulties  and  dangers 
of  a  radical  operation,  and  convinces  me  that  in  spite  of  the  improved 
technique  of  the  day  it  is  still  wise  to  follow  the  old  rule  of  absten- 
tion in  all  cases  in  which  the  danger  of  secondary  hemorrhage  is  past 
and  the  arterio-venous  anastomosis  is  well  tolerated.  While  accepting 
this  conservative  attitude  as  the  proper  one  in  old-established  cases,  I 
do  believe  that  the  indications  for  interference  and  radical  operation 
have  broadened,  and  that  the  surgeon  is  thoroughly  justified  in  oper- 
ating in  all  favorable  cases  whenever  the  lesion  causes  disturbance  and 
threatens  complications. 


AN  OPERATION  FOR  THE  RADICAL  CURE  OF 
UMBILICAL  HERNIA. 


By  WILLIAM  J.  MAYO,  A.M.,  M.D. 

ROCHESTER,   MINN. 


The  results  of  operation  for  the  radical  cure  of  umbilical 
hernia  in  adults  have  not  been  encouraging.  These  patients 
are  usually  obese,  with  attenuated  abdominal  muscles,  and  the 
thin,  rigid  character  of  the  ring  does  not  offer  mechanical  con- 
ditions advantageous  to  lasting  union. 

The  principles  of  closure  have  been  the  same  as  after  an  ordi- 
nary abdominal  section,  the  object  being  to  split  the  fascia  at 
the  ring  margins  laterally,  until  the  recti  muscles  are  reached, 
and  then  by  a  series  of  buried  sutures  to  reconstruct  the  abdom- 
inal wall  in  layers.  The  defect  in  this  method  is  the  natural 
separation  of  the  recti  muscles  at  the  level  of  the  umbilicus. 
Below  this  point  the  muscular  structures  are  practically  in  con- 
tact, but  above  there  is  normally  from  one-fourth  to  three-fourths 
of  an  inch  separation.  To  bring  the  recti  together  in  this 
locality  amounts  to  a  muscle  transplantation.  In  small  hernias 
this  muscular  approximation  is  not  difficult,  but  in  the  larger 
openings  an  inch  or  more  in  diameter  it  is  impracticable,  and  so 
far  as  I  have  been  able  to  judge  the  attenuated  muscles,  when 
secured,  are  not  of  great  value  as  retentive  agents  in  this  variety 
of  hernia.  In  very  corpulent  subjects  the  muscular  separation 
is  greater.  If  such  a  patient,  lying  on  the  back,  be  directed  to 
rise,  bringing  into  play  the  recti  muscles,  the  lateral  deviation 
at  the  level  of  the  umbilicus  is  easily  shown,  and,  in  the  majority 
of  cases,  demonstrates  the  impossibility  of  bringing  them  firmly 
into  median  apposition. 


Fig.  I. 


Showing  exposure  of  hernia  and  lateral  incisions. 


RADICAL    CURE    OF    UMBILICAL    HERNIA.  297 

Lucus  Chanipionnicre,  after  making  a  plea  for  operation  in 
the  acquired  umbilical  hernia  of  adults,  well  says  that,  although 
the  operation  frequently  fails,  the  relapse  is  less  uncomfortable 
to  the  patient  and  has  less  danger  of  strangulation  than  the 
original  hernia.  This  is  especially  true  of  relapses  after  division 
of  the  umbilical  ring;  the  return  partakes  more  of  the  nature  of 
a  ventral  hernia,  the  internal  opening  being  nearly,  if  not  quite, 
the  diameter  of  the  protrusion.  The  late  Grieg  Smith'  directed 
that  the  incision  should  be  made  over  the  thinnest  part  of  the 
umbilical  sac,  and  this  advice  seems  to  have  been  generally 
adopted. 

Ransohofif,-  in  a  practical  paper,  calls  attention  to  the  loss  of 
time  in  dissecting  down  through  one  of  these  protrusions  filled 
with  adherent  viscera,  in  danger  constantly  of  wounding  im- 
portant structures,  and  lays  down  the  principle  that  the  incision 
should  always  be  made  into  the  free  abdominal  cavity  at  the 
neck  of  the  hernia.  This  at  once  allows  an  inspection  of  its 
contents  and  return  of  intestinal  coils,  if  present.  The  adherent 
omentum  can  be  ligated  at  the  internal  opening,  saving  both 
time  and  trouble.  In  strangulated  conditions,  as  pointed  out 
by  Barton,  the  knuckle  of  pinched  intestine  is  usually  in  the 
centre  of  the  adherent  omentum,  and  with  this  form  of  incision 
the  operator  is  in  no  danger  of  injuring  the  bowel.  Ransohoff 
used  silver  wire  in  his  reported  cases  as  permanent  sutures,  and 
we  have  followed  the  same  plan.  Silver  wire  buried  in  bone 
and  aponeurosis  seldom  gives  trouble,  because  it  lies  in  fixed 
tissues,  although  in  movable  structures  like  muscle,  atrophy 
necrosis  may  occur  and  necessitate  its  removal.  Wheaton^  ad- 
vocates operation  in  the  larger  varieties  of  umbilical  hernia  on 
account  of  the  extreme  disability  which  it  causes,  and  in  this 
class  of  cases  brings  up  the  question  as  to  the  return  of  the 
contents  of  large  hernias,  especially  when  they  have  been  irre- 
ducible for  more  than  two  years.  In  this  time,  he  says,  ''The 
extruded  viscera  has  lost  the  right  of  habitation,"  and  recom- 
mends   that   before    operation   the   patient  be  kept   in  bed  for 

'  Annals  of  Surgery,  1895.  '''  Medical  Record,  1897. 

3  St.  Paul  Medical  Journal,  December,  1900. 


298  MAYO, 

several  weeks,  and  means  taken  to  reduce  the  body-weight.  We 
have  followed  this  method,  and  after  removal  of  sufficient  omen- 
tum have  seldom  had  trouble  in  returning  the  hernial  contents. 

In  a  paper  read  before  the  American  Academy  of  Railway 
Surgeons  on  October  4,  1898,  and  published  in  the  Annals  of 
Surgery  for  January,  1899,  I  called  attention  to  the  imprac- 
ticability of  covering  in  the  defect  left  by  excision  of  the  larger 
umbilical  hernia  with  muscle,  and  advocated  the  overlapping 
of  the  aponeurotic  structures  which  were  already  at  hand, 
securing  a  wide  area  of  adhesions  in  place  of  edge-to-edge 
union.  This  method  we  had  then  employed  in  five  cases,  in 
three  the  overlapping  was  from  side  to  side,  and  in  two  from 
above  down.  Extensive  lateral  incisions  to  find  sufficient 
muscle  to  make  the  routine  operation  described  by  surgical 
writers  compelled  us  as  a  matter  of  necessity  to  overlap  from 
above  downward,  and  to  our  satisfaction  we  found  the  parts 
came  together  with  less  tension  than  when  drawn  laterally,  and 
time  proved  that  the  strength  of  the  union  was  as  lasting. 

The  first  of  these  overlapping  operations  was  done  in  1895. 
We  have  now  made  this  operation  nineteen  times,  ten  times 
overlapping  from  side  to  side  and  nine  times  from  above  down- 
ward. The  larger  openings  have  usually  been  more  easily 
closed  by  the  latter  method.  The  principle  employed  is  not 
unlike  the  Championniere  operation  for  the  radical  cure  of 
inguinal  hernia.  In  Championniere's  method  the  external 
oblique  is  overlapped  in  a  similar  manner  to  the  operation 
described,  and  his  results  in  800  cases  have  not  been  excelled. 

The  method  of  radical  cure  of  inguinal  hernia  suggested  by 
E.  W.  Andrews  also  depends  upon  the  overlapping  of  the  fascia 
of  the  external  oblique  for  its  success. 

The  umbilical  operation  is  performed  as  follows  : 

1.  Transverse  elliptical  incisions  are  made  surrounding  the 
umbilicus  and  hernia  ;  this  is  deepened  to  the  base  of  the  hernial 
protrusion. 

2.  The  surface  of  the  aponeurotic  structures  are  carefully 
cleared  an  inch  and  a  half  in  all  directions  from  the  neck  of 
the  sac. 


RADICAL    CURE    OF    UMBILICAL    HERNIA.  299 

3.  The  fibrous  and  peritoneal  coverings  of  the  hernia  are 
divided  in  a  circular  manner  at  the  neck,  exposing  its  contents. 
If  intestinal  viscera  are  present  the  adhesions  are  separated  and 
restitution  made.  The  contained  omentum  is  ligated  and  re- 
moved with  the  entire  sac  of  the  hernia. 

4.  With  forceps  the  margins  of  the  ring  are  grasped  and 
approximated  ;  whichever  way  the  overlapping  is  more  easy  of 
accomplishment  suggests  the  direction  of  closure.  The  figures 
show  the  overlapping  as  done  from  above  downward. 

5.  For  this  approximation  an  incision  is  made  through  the 
aponeurotic  and  peritoneal  structures  of  the  ring,  extending  one 
inch  or  more  transversely  to  each  side,  and  the  peritoneum  is 
separated  from  the  under  surface  of  the  upper  of  the  two  flaps 
thus  formed. 

6.  Beginning  one  inch  or  more  above  the  margin  of  the  upper 
flap,  three  to  four  silver  wire  mattress  sutures  are  introduced,  the 
loop  firmly  grasping  the  upper  margin  of  the  lower  flap,  suf- 
ficient traction  is  made  on  these  sutures  to  enable  peritoneal 
approximation  with  running  suture  of  catgut.  The  mattress 
sutures  are  then  drawn  into  position,  sliding  the  entire  lower 
flap  into  the  pocket  previously  formed  between  the  aponeurosis 
and  the  peritoneum  above. 

7.  The  free  margin  of  the  upper  flap  is  fixed  by  catgut  sutures 
to  the  surface  of  the  aponeurosis  below,  and  the  superficial 
incision  closed  in  the  usual  manner.  The  lateral  approxima- 
tion is  carried  out  by  sliding  one  side  under  the  other  in  the 
same  manner.  In  the  larger  hernise  the  incision  through  the 
fibrous  coverings  of  the  sac  may  be  made  somewhat  above  the 
base,  thereby  increasing  the  amount  of  tissue  to  be  used  in  the 
overlapping  process.  In  only  one  case  were  we  unable  to  satis- 
factorily close  the  opening,  as  described,  on  account  of  the  large 
size  of  the  umbilical  ring.  In  this  case  less  than  one-half  an 
inch  of  overlapping  was  secured,  and  that  under  great  tension, 
The  result  was  a  boat-shaped  stretching  of  the  united  parts,  but 
the  symptomatic  cure  was  excellent.  The  results  in  the  other 
cases,  so  far  as  known,  have  been  good,  although  many  of  them 
are  too  recent  to  be  called  cured,  and  possibly  relapses  will  occur. 


3C0  MAYO, 

Piccoli^  reports  a  case  successfully  operated  upon  in  August, 
1899,  after  a  similar  plan,  and  refers  to  a  case  reported  by 
Bonomo  operated  upon  December  9,  1899,  with  a  favorable 
result.  J.  A.  Blake^  reports  several  cases  operated  upon  by  the 
same  method  during  1900,  and  refers  to  an  article  by  Sapiejko/ 
in  which  an  identical  operation  is  described.  It  is  evident  that 
a  number  of  operators  have  independently  worked  out  the  same 
idea.     All  reported  favorable  results. 

1  Centralblatt.  f.  klin.  Chir.,  Jan.  13,  1900. 

2  Medical  Association  of  Greater  New  York,  January  14,  1901. 

3  Rev.  de  Chir.,  1900,  No.  2,  p.  240. 


RADICAL    CURE    OF    UMBILICAL    HERNIA.  3OI 


DISCUSSION. 

Dr.  A.  J.  OcHSNER,  of  Chicago. 

There  are  four  methods  of  treatment  of  umbilical  hernia  in  the 
adult  which  seem  worthy  of  consideration  : 

1.  The  method  consisting  in  the  excision  of  the  umbilical  ring  and 
the  closure  of  the  defect  by  several  rows  of  sutures  as  recommended 
by  Quenu,  Gersuny,  Ransohoff,  Championniere  and  others.  In  this 
method  five  layers  are  sutured  separately  :  i.  Peritoneum  and  trans- 
versalis  fascia.  2.  Posterior  fascia  of  rectus  abdominis  muscle.  3.  The 
rectus  abdominis  muscle  on  each  side  to  its  fellow.  4.  The  anterior 
fascia  of  the  rectus  abdominis  muscle.  5.  The  skin  and  superficial 
fascia.  Some  authors  insert  tension  sutures,  passing  through  all  of 
these  layers  down  to  the  first  one  mentioned,  which  are  left  until  all 
of  the  layers  have  been  sutured  separately  and  then  tied  for  the  pur- 
pose of  relieving  the  tension  upon  the  sutures  applied  to  the  various 
layers.  Others  depend  entirely  upon  the  sutures  applied  to  the  dif- 
ferent layers.  Various  suture  materials  are  used  by  the  different  authors, 
from  ordinary  catgut  to  metallic  sutures. 

2.  Various  methods  involving  splitting,  crossing,  or  transplanting 
portions  of  the  recti  muscles  have  been  recommended,  especially  by 
Dauriac  in  France  and  Scatolari  in  Italy. 

3.  The  implantation  of  aseptic  sponge  or  gold  or  silver  wire  net- 
work has  been  praised  by  Witzel,  Phelps  and  others.  This  method 
has  not  been  tried  for  a  sufficient  time  to  enable  one  to  judge  of  its 
value. 

4.  The  method  first  described  by  Dr.  Mayo  several  years  ago,  as 
brought  forth  in  the  paper  under  discussion. 

The  first  method  described  I  have  used  in  a  number  of  cases  with 
satisfactory  results  only  when  the  separation  between  the  recti  muscles 
has  not  been  great,  and  when  the  latter  structures  had  not  atrophied 
to  too  great  an  extent.  This  condition,  however,  is  exceedingly 
common  in  very  obese  patients.  About  three  years  ago  Dr.  Mayo 
showed  me  his  method,  and  since  then  I  have  employed  it  in  seven 
cases.     In  these  cases  I  have  used  chrome-catgut  sutures. 

Case  I. — January  26,  1899,  I  operated  upon  Mrs.  A.  B.,  aged 
thirty-one  years,  suffering  from  an  umbilical  hernia  the  size  of  an 
orange.  I  made  the  typical  operation,  and  she  left  the  hospital  in  five 
weeks  perfectly  well.     She  has  had  no  recurrence. 


302  DISCUSSION. 

Case  II. — On  July  ii,  1899,  Mrs.  W.,  a  woman,  aged  fifty-eight 
years,  weighing  over  300  pounds,  who  had  suffered  from  an  umbilical 
hernia  the  size  of  a  hen's  egg  for  a  number  of  years.  It  had  become 
violently  strangulated  twelve  hours  before  I  saw  her.  When  first  seen 
by  me  the  skin  covering  the  hernia  was  black  and  very  thin,  so  that 
the  dark-colored  omentum  could  be  seen  through  it.  I  opened  the 
sac,  replaced  a  portion  of  the  transverse  colon  which  had  been  strangu- 
lated, and  removed  the  sac.  The  ring  was  an  inch  in  diameter,  but 
the  piece  of  transverse  colon  had  been  forced  into  the  sac  and  held 
there  by  the  pedicle  of  a  mass  of  omentum  which  had  evidently  been 
adherent  for  a  long  time  to  the  neck  of  the  sac.  The  discolored 
omentum  was  ligated  and  removed  and  the  stump  replaced.  Then 
the  opening  was  closed  transversely  by  Mayo's  method.  The  patient 
recovered  and  has  had  no  recurrence. 

Case  III. — December  10,  1899,  I  operated  upon  Mrs.  M.  R.,  aged 
fifty  years.  The  patient  was  suffering  from  a  painful  umbilical  hernia 
as  large  as  a  hen's  egg.  The  same  operation  was  performed,  with  the 
same  result.     She  remained  in  the  hospital  four  weeks. 

Case  IV. — Mrs.  O.  J.,  aged  fifty-four  years,  also  a  very  obese  patient, 
came  to  me  for  treatment  of  umbilical  hernia  October  8,  1900.  I 
placed  her  on  a  restricted  diet  and  advised  walking  long  distances. 
On  December  7,  1900,  she  returned  with  her  weight  reduced  thirty 
pounds.  The  hernia  was  as  large  as  a  fist,  and  contained  adherent 
omentum.  The  adhesions  were  loosened  and  the  omentum  replaced 
and  the  opening  closed  transversely  by  Mayo's  method.  She  left  the 
hospital  four  weeks  after  the  operation  with  her  weight  still  further 
reduced  twenty  pounds. 

Case  V. — Dr.  G.  E.  M  ,  a  very  obese  patient,  who  had  acquired  a 
very  painful  umbilical  hernia,  the  size  of  a  hen's  egg,  in  a  runaway 
accident  five  years  ago,  came  to  me  February  17,  1901.  The  hernia 
contained  adherent  omentum.  I  performed  Mayo's  operation,  and 
he  went  home  well,  three  weeks  after  the  operation.  In  a  letter  just 
received  he  states  that  his  abdominal  wall  is  strong,  and  that  he  is  as 
well  as  before  his  accident. 

Case  VI. — Mrs.  H.  W.,  a  very  obese  woman,  aged  forty-two  years, 
came  to  the  hospital  February  18,  1901,  suffering  from  a  painful  um- 
bilical hernia  the  size  of  half  an  egg.  I  performed  the  same  opera- 
tion, and  she  left  the  hospital  well  four  weeks  after  the  operation. 

Case  VII. — An  obese  woman,  aged  sixty-seven  years.  I  have  just 
operated,  April  26,  1901. 


RADICAL    CURE    OF     UMBILICAL     HERNIA. 


303 


Of  course,  the  time  in  all  of  these  cases  is  too  short  to  justify  any 
conclusions,  but  I  have  been  impressed  with  the  value  of  this  opera- 
tion as  compared  with  the  others.  I  believe  that  every  surgeon  who 
has  once  tried  this  operation  will  be  convinced  of  its  value.  After 
the  operation  has  been  completed  vomiting  or  straining  does  not  seem 
to  make  any  impression  upon  the  repaired  portion  of  the  abdominal 


wall,  and  in  all  of  my  cases  the  patient  has  felt  perfectly  secure  ever 
after  the  operation.  I  have  been  in  the  habit  of  supporting  the 
abdomen  with  broad  rubber  adhesive  plaster  strips  for  two  months 
after  the  operation.  These  patients  have  also  all  been  advised  to  sub- 
ject themselves  to  a  moderate  diet  and  to  walk  a  great  deal  to  increase 
their  muscles  and  to  decrease  their  fat. 

In  looking  over  the  literature  of  the  subject  I  have  encountered  an 


304  DISCUSSION. 

article  by  Dr.  E.  Piccoli,  an  Italian  surgeon  (^Centralblait  f.  Chir., 
January  13,  1900),  in  which  exactly  this  same  operation  is  described, 
as  is  shown  by  the  accompanying  illustration.  The  author  had  per- 
formed this  operation  once,  on  August  29,  1899,  which  was  long  after 
it  had  been  described  and  practised  by  Dr.  Mayo,  and  eight  months 
after  my  first  operation.  He  states  in  his  article  that  Dr.  Bonomo 
reported  at  the  Congress  of  Italian  Surgeons  in  Rome  on  December 
9,  1899,  that  he  had  also  invented  and  practised  a  method  which  is  in 
all  essential  respects  identical  with  Dr.  Piccoli's  and,  as  we  see  also, 
with  Dr.  Mayo's  method. 

The  method  has  so  much  to  recommend  it  that  it  is  not  at  all  sur- 
prising that  it  should  have  been  invented  independently  by  at  least 
three  different  surgeons.  Of  these  Dr.  Mayo  was  undoubtedly  first 
by  several  years  in  point  of  time,  although,  of  course,  this  fact  is  of 
very  little  importance.  In  connection  with  every  method  the  plan 
of  reducing  the  weight  of  the  patient  due  to  obesity  is  of  primary 
importance. 

Dr.  F.  H.  Gerrish,  of  Portland,  Maine. 

There  is  a  certain  class  of  cases  which  gives  me  some  concern,  and 
that  is  those  of  congenital  umbilical  hernia,  which  we  often  cure  by  a 
simple  truss,  but  which  occasionally  run  on  for  years  without  a  cure. 
I  would  like  to  ask  Dr.  Mayo  what  he  does  in  these  cases. 

Dr.  De  Forest  Willard,  of  Philadelphia. 

I  remember  performing  an  umbilical  operation  that  gave  me  an 
unusual  amount  of  difficulty  on  account  of  the  enormous  obesity  of 
the  patient,  who  weighed  500  pounds,  and  I  was  obliged  to  work 
through  an  incision  about  eight  inches  deep  through  solid  fat.  The 
operation  has  successfully  stood  the  test  of  eight  years.  The  case  was 
one  of  strangulated  hernia  in  the  centre  of  a  large  mass  of  omentum. 
After  reducing  the  bowel  I  drew  out  more  omentum  than  had  been 
previously  herniaized,  ligated  and  cut  it  away.  I  could  not  bring  the 
recti  muscles  together  on  account  of  the  fat ;  consequently  I  fastened 
the  omental  stump  to  the  peritoneum  at  the  umbilicus  and  made  it 
the  plug,  after  freshening  the  sides  of  the  opening.  The  huge  mass 
of  fat  and  skin  was  drawn  together  by  several  layers  of  suture,  and 
the  last  I  heard  of  the  patient  she  had  a  good  abdominal  wall.  In 
ligating  off  the  omentum  it  is  always  important  to  take  away  a  larger 


RADICAL    CURE    OF    UMBILICAL    HERNIA.  305 

portion  than  has  been  prolapsed  previously.     The  tendency  to  relapse 
is  thereby  greatly  diminished. 

Dr.  a.  J.  McCosH,  of  New  York. 

I  remember  a  case  of  ventral  hernia  in  a  young  fat  woman  from 
whom  there  had  been  removed  a  large  fibromyoma  of  the  abdominal 
wall.  She  came  to  me  about  three  years  ago  with  a  large  hernia  which 
she  could  not  control  on  account  of  the  large  opening  in  the  abdom- 
inal wall,  due  to  removal  of  the  muscle.  After  exposing  the  opening 
I  found  it  was  impossible  to  bring  the  muscles  together,  so  I  filled  up 
the  gap  with  a  celluloid  plate  about  four  by  five,  inserting  it  between 
the  peritoneum  and  the  external  oblique  muscle,  tucking  it  under  the 
edges  of  the  latter.  The  plate  was  perforated  by  twenty- five  or  thirty 
perforations  made  with  a  ticket  punch.  The  exterior  of  the  peri- 
toneum was  scraped  and  the  skin  wound  sutured  over  it.  Although 
this  was  nearly  three  years  ago,  the  woman  is  still  perfectly  comfort- 
able. She  wears  a  light  abdominal  bandage,  and  there  is  no  sign  of 
irritation  from  the  plate,  nor  any  evidence  of  hernial  protrusion. 
While  I  do  not  recommend  the  method,  it  is  a  procedure  which  may 
be  tried  in  cases  where  considerable  portions  of  the  abdominal  wall 
have  been  removed. 

Dr.  W.  B.  Coley,  of  New  York. 

I  have  had  a  very  large  experience  in  the  observation  of  these  cases, 
and  several  years  ago  I  operated  on  a  considerable  number.  The 
results  were  bad,  and  at  least  50  per  cent,  relapsed  in  from  a  few 
months  to  a  few  years.  Contrary  to  the  experience  of  Dr.  Mayo,  the 
after- history  of  my  cases  which  relapsed  were  not  as  good  as  before 
operation.  The  omentum  came  back  and  became  adherent,  and  the 
local  irritation  was  worse  than  the  condition  before  operation.  The 
results  of  operation  on  a  large  number  of  these  cases  by  one  of  my 
colleagues  have  convinced  us  that  they  are  not  improved.  Of  course,. 
I  am  referring  now  only  to  large  fat  people,  and  I  am  sure  they  have 
not  derived  any  good  by  operations  that  have  been  done  in  the  past.. 
The  operation  as  performed  in  New  York  differs  somewhat  from  Dr.. 
Mayo's.  Whether  or  not  the  new  operations  are  going  to  give  us 
better  results  than  the  old  ones  it  is  hard  to  determine.  We  are  not 
able  to  say  whether  the  condition  is  benefited  by  the  new  operation, 
as  sufficient  time  has  not  elapsed.     There  is  considerable  risk  in  oper- 

Am  Surg  20 


306  RADICAL    CURE    OF    UMBILICAL    HERNIA. 

ating  on  some  of  these  cases,  and  unless  we  can  cure  them  the  ques- 
tion of  operation  is  one  hard  to  decide. 

Dr.  J.  Collins  Warren,  of  Boston. 

It  has  been  stated  that  the  etiology  of  this  condition  is  important, 
and  I  am  sure  this  is  so.  It  has  seemed  to  me  that  cases  of  acquired 
umbilical  hernia  are  due  to  the  development  of  a  large  fold  of  abdom- 
inal wall  which  pulls  upon  the  umbilical  cicatrix.  In  this  way  we 
have  the  beginning  of  the  hernia,  and  it  is  possible  that  we  may  find 
less  tendency  if  the  large  fold  of  abdominal  wall  is  removed,  as  has 
been  done  in  some  cases  already,  both  for  anaesthetic  purposes  and 
for  comfort.  I  shall  look  with  interest  to  see  whether  cases  operated 
upon  with  that  end  in  view  have  a  recurrence. 

As  to  the  method  of  suturing,  I  prefer  also  to  suture  from  above 
downward  rather  than  the  lateral,  and  I  think  a  better  adjustment  can 
thus  be  made.  The  peritoneum  should  be  thoroughly  separated.  I 
have  never  tried  the  overlapping  method.  The  suture  material  I  prefer 
is  silk. 

Dr.  Mayo.  I  have  not  operated  on  cases  similar  to  those  described 
by  Dr.  Gerrish.  As  to  the  amount  of  omentum  to  be  removed, 
referred  to  by  Dr.  Warren,  I  think  we  should  remove  whatever  is  in 
the  sac.  If  the  sac  also  contains  intestine  which  is  constantly  ex- 
truded, we  should  remove  enough  omentum,  previously  contained  in 
the  abdomen,  to  allow  for  the  intestine  we  wish  to  restore. 

In  reply  to  Dr.  Coley  concerning  relapses,  I  would  state  that  I 
have  seen  only  one,  and  this  one  is  very  comfortable.  I  have  never 
seen  any  deaths,  and  see  no  reason  why  there  should  be,  unless  acci- 
dentally.    Of  course,  in  strangulated  cases  there  are  many  deaths. 

I  was  glad  to  hear  Dr.  Warren's  remarks  in  reference  to  suturing 
from  above  downward,  as  I  did  it  in  this  way  of  necessity  in  my  first 
case,  against  my  own  judgment. 


PREVENTION  AND   CURE  OF  POST-OPERATIVE 
HERNIA. 


By  JAMES  E.  MOORE,  M.D., 

MINNEAPOLIS   MINN. 


A  PAPER  on  this  subject  must  necessarily  be  short  because  the 
subject  is  a  small  one  at  the  present  time,  but  we  can  all  remem- 
ber when  it  was  very  large  and  important. 

Modern  surgeons  very  rarely  see  a  post-operative  hernia  fol- 
lowing their  operations  except  after  operations  for  acute  appen- 
dicitis in  which  they  have  been  obliged  to  drain.  In  the 
controversy  between  the  advocates  of  abdominal  and  vaginal 
hysterectomy  the  fear  of  a  ventral  hernia  should  no  longer  be  an 
argument  against  the  abdominal  route  because  an  operator  com- 
petent to  perform  hysterectomies  will  not  have  hernia  follow 
his  operations.  All  the  ventral  herniae  I  have  seen  during  the 
past  three  years,  with  one  single  exception,  have  either  followed 
acute  appendicitis  operations,  in  which  it  was  necessary  to  drain, 
or  operations  performed  by  "  occasional  operators."  The  one 
exception  was  in  a  hitmophiliac  who  had  had  her  wound  packed 
to  save  her  life. 

The  causes  of  ventral  hernia  are  sepsis,  improper  closing  of 
the  wound  and  drainage.  It  follows  that  hernia  is  to  be  avoided 
by  asepsis,  proper  closing  of  the  wound,  and  by  avoiding  drain- 
age. Upon  the  question  of  asepsis  we  all  practically  agree,  but 
concerning  the  closure  of  the  wound  there  are  still  differences 
of  opinion.  This  was  very  manifest  in  the  discussion  of  Dr. 
Richardson's  paper  last  year.  At  one  time  it  was  believed  that 
a  hernia  was  more  frequently  the  result  of  an  improperly  made 
or  located  wound  than  of  an  improperly  closed  one,  but  at  the 


308  MOORE, 

time  when  we  were  all  having  some  ventral  herniae  we  were  more 
particular  as  to  the  location  of  the  wound  than  we  are  now. 
While  we  always  prefer  to  make  the  wound  parallel  with  the 
fibres  of  the  tissues,  we  do  not  hesitate  to  cut  crosswise  when  a 
cross  incision  will  better  expose  the  field  of  operation,  for  we 
know  that  by  a  careful  closing  of  the  wound  we  need  not  fear 
hernia.  When  we  first  began  to  perform  appendicitis  opera- 
tions it  was  believed  that  our  hernias  were  due  to  the  cutting  of 
the  muscles  crosswise,  but  we  can  make  a  short  cross-incision 
now  when  operating  for  chronic  appendicitis  and,  by  closing 
the  wound  accurately  and  aseptically,  can  avoid  a  hernia. 

When  we  cut  muscular  fibres  across  in  other  parts  of  the  body 
we  expect  them  to  unite  when  properly  approximated.  Why 
not  expect  the  same  of  the  abdominal  muscles  ? 

The  fact  that  every  experienced  surgeon  believes  that  his  par- 
ticular method  of  closing  the  abdominal  wound  the  best,  proves 
that  when  certain  rational  principles  are  adhered  to  the  partic- 
ular method  of  carrying  them  out  is  of  less  importance  than  we 
are  apt  to  believe.  The  nearer  we  approach  nature's  method 
the  more  rational  we  are.  We  are  certainly  following  nature's 
method  when  we  close  a  wound  by  uniting  fascia  to  fascia, 
muscle  to  muscle,  and  peritoneum  to  peritoneum,  and  we 
certainly  are  not  following  nature's  methods  when  we  bury 
unabsorbable  material  in  the  wound.  Dr.  Coley  stated  in  his 
discussion  of  Dr.  Richardson's  paper  last  year  that  he  had  seen 
thirty  cases  of  sinus  due  to  buried  unabsorbable  sutures.  We 
rarely  meet  with  a  sinus  in  the  Nort'nwest  because  of  the  uni- 
versal use  of  absorbable  ligatures  and  sutures. 

I  will  describe  briefly  the  method  I  have  employed  for  several 
years  in  closing  the  abdominal  wound  and  give  my  reasons  for 
preferring  it.  This  is  also  the  method  employed  by  all  of  the 
surgeons  who  operate  in  the  same  hospitals  with  me,  except 
my  colleague,  Dr.  A.  W.  Abbot,  who  uses  the  crossed  suture  of 
Dr.  Fowler,  with  some  slight  modifications. 

The  peritoneum  is  first  closed  by  a  running  stitch  of  medium- 
weight  catgut.  Silkworm-gut  sutures  are  next  passed  through 
all  of  the  tissues  except    the  peritoneum,  by  means  of  a  full- 


POST-OPERATIVE    HERNIA.  3O9 

curved  needle  of  a  size  suited  to  the  thickness  of  the  abdominal 
wall.  The  needle  passes  from  without  inward  through  the 
integument,  fascia,  muscle,  and  deep  fascia,  coming  out  next  to 
the  peritoneum.  It  then  passes  from  within  out  through  the 
inner  fascia,  muscle,  outer  fascia,  and  integument.  In  a  very- 
thin  abdominal  wall  the  needle  can  be  passed  through  both 
edges  of  the  wound  at  one  sweep,  but  in  most  cases  it  is  better 
to  take  them  separately.  These  stitches  are  placed  about 
half  an  inch  apart.  The  fascia  of  the  external  oblique  is  next 
united  by  a  running  stitch  of  medium  weight  catgut.  All  of 
the  ends  of  the  silkworm-gut  are  now  caught  and  pulled  upon 
at  once,  so  that  they  are  made  taut,  after  which  they  are  tied 
lightly.     Extra  skin  sutures  are  applied  when  needed. 

The  advantages  of  this  method  are :  First,  the  peritoneal 
cavity  is  closed  without  delay ;  second,  there  is  no  unabsorb- 
able  material  left  in  the  tissues  to  make  future  trouble ;  third, 
the  suturing  of  the  outer  fascia  gives  such  support  that  the  silk- 
worm sutures  need  not  be  tied  so  tight  as  to  cause  necrosis ; 
fourth,  it  obliterates  all  dead  space,  and,  lastly,  it  yields  eminently 
satisfactory  results.  The  catgut  used  is  sterilized  by  the  dry- 
heat  process  of  Boeckmann,  and  is  always  sterile.  The  advan- 
tage claimed  for  passing  the  needle  from  within  out  is  only 
theoretical,  for  I  have  not  taken  the  time  to  do  this,  and  since 
I  have  worn  rubber  gloves  stitch  abscesses  are  practically 
unknown  in  my  work. 

Dr.  Abbot's  cross-stitch  differs  from  Dr.  Fowler's  original 
suggestion  in  two  points.  He  first  closes  the  peritoneum  with 
catgut,  and,  instead  of  tying  over  rubber  tubes,  he  ties  the  two 
ends  together,  just  as  we  do  in  the  through-and-through  stitch. 
After  closing  the  peritoneum  he  takes  a  thread  of  silkworm- 
gut  with  a  medium-sized  needle  on  each  end,  and  passes  one 
needle  from  within  out;  first,  through  the  deeper  fascia,  then 
across  through  the  muscle  and  outer  fascia  of  the  opposite  side; 
then  across  through  the  integument  of  the  original  side.  He  then 
takes  the  other  needle  and  passes  it  from  within  outward,  just 
as  he  did  the  first,  but  beginning  on  the  opposite  side.  This  is 
an  excellent  stitch,  for  it  brings  the  tissues  together,  layer  by 


3IO  MOORE, 

layer,  and  leaves  no  dead  space.  There  are,  however,  two 
objections  to  it :  it  requires  much  more  time  to  apply  it,  and 
causes  the  patient  more  pain  when  it  is  removed. 

In  most  cases  of  acute  appendicitis,  drainage  through  the 
abdominal  wound  cannot  be  avoided,  but  the  wound  should  be 
partly  closed,  leaving  just  sufficient  room  for  drainage.  In  the 
few  cases  of  pelvic  surgery  requiring  drainage,  it  is  safer  and 
better  in  every  way  to  drain  through  the  vagina. 

The  same  rules  should  govern  the  treatment  of  post-operative 
hernia  that  apply  to  other  varieties  of  hernia.  When  a  patient 
applies  to  a  surgeon  for  advice  the  rule  should  be  to  advise 
operative  treatment.  Mechanical  treatment  is  unsatisfactory,  and 
is  only  palliative  at  best.  The  tendency  is  for  the  hernia  to 
grow  larger  and  for  the  surrounding  tissues  to  undergo  changes, 
so  that  the  chances  for  a  successful  operation  diminish  with 
time. 

Until  quite  recently  the  tone  of  the  literature  upon  the  treat- 
ment of  ventral  hernia  was  quite  pessimistic,  because  it  was 
written  when  ventral  hernia  was  quite  common.  It  follows  that 
an  operator  who  has  had  hernia  follow  his  operations  frequently 
would  often  fail  in  his  efforts  to  cure  the  hernia. 

At  the  present  time  the  prognosis  in  the  operative  treatment 
of  ventral  hernia  is  good.  My  results  since  employing  the  tech- 
nique described  in  this  paper  have  been  as  good  as  those  fol- 
lowing operations  for  inguinal  hernia.  When  we  undertake  to 
cure  a  ventral  hernia  we  should  endeavor  to  restore  the  tissues 
to  their  normal  relations,  and  hold  them  there  by  artificial 
means  until  nature  has  had  time  to  unite  them  firmly.  I  believe 
that  it  is  unwise  to  go  beyond  this  and  try  to  assist  nature 
permanently  by  burying  unabsorbable  material  in  the  tissues, 
and  I  know  from  personal  experience  that  it  is  unnecessary 

It  is  just  as  important  to  enter  the  peritoneal  cavity  and  remove 
the  sac  in  this  variety  of  hernia  as  in  any  other  variety.  The 
entrance  should  be  made  well  away  from  the  cicatricial  tissue 
for  fear  of  injuring  an  adherent  intestine.  All  of  the  scar  tissue 
should  be  dissected  away,  and  the  various  layers  of  the  abdomi- 
nal wall  carefully  isolated.     When  this  has  been  accomplished 


POST-OPERATIVE     HERNIA.  3II 

the  Operation  resolves  itself  into  the  closure  of  an  abdominal 
wound.  The  wound  should  be  closed  by  through-and-through 
sutures  of  silkworm-gut  and  buried  animal  sutures,  the  method 
differing  from  the  closing  of  an  ordinary  abdominal  wound  only 
in  that  the  silkworm  sutures  should  be  much  closer  together, 
and  the  buried  sutures  should  be  of  kangaroo  tendon  or  chromi- 
cized  catgut,  because  the  tension  is  greater  and  the  tissues  are 
not  in  so  favorable  a  condition  for  healing. 

It  has  recently  been  suggested  that  we  use  silver  wire  sutures 
wound  around  a  piece  of  ivory,  together  with  buried  sutures  of 
kangaroo  tendon.  (See  Medica/ Nezvs,  September  i,  igoo.)  The 
reported  results  are  good,  and  the  method  is  doubtless  a  good 
one;  but  this  return  to  the  old  quill  sutures  seems  like  a  step 
backward,  and  it  is  unnecessary. 

Next  to  asepsis  the  most  important  step  in  this  operation  is 
the  separation  of  the  various  tissues  by  careful  dissection.  A 
simple  cutting  out  of  the  scar  and  bringing  the  freshened  edges 
together  is  very  liable  to  lead  to  disappointment.  It  is  of  spe- 
cial importance  to  bring  the  muscular  layers  together,  because  it 
is  the  best  protection  against  a  hernia.  We  do  not  find  this 
tissue  in  the  covering  of  a  hernia.  In  a  median  hernia  it  is  often 
necessary  to  open  the  sheaths  of  the  recti  in  order  to  bring  the 
muscles  together. 

After  the  operation  the  patient  should  be  kept  in  bed  at  least 
three  weeks,  to  give  the  tissues  ample  time  to  heal  before  weight 
is  thrown  upon  them.  When  the  patient  is  very  fat,  it  is  often 
advisable  to  keep  him  in  bed  on  a  milk  diet  for  three  or  four 
weeks  before  the  operation,  just  as  we  do  in  umbilical  hernia  in 
fat  people.  Patients  with  pendulous  abdomens  should  wear  an 
abdominal  support  after  the  operation,  but  spare  persons  do  not 
need  it. 


312  DISCUSSION. 


DISCUSSION. 

Dr.  Arthur  Dean  Bevan,  of  Chicago. 

As  to  the  non-absorbable  sutures,  they  form  sinuses,  it  is  said,  and  it 
is  claimed  that  to  use  non-absorbable  gut  is  no  longer  to  be  regarded 
as  good  surgery,  but  it  has  been  demonstrated  beyond  question  that  it 
is  not  the  best  surgery.  A  catgut  suture  can  be  so  well  prepared  and 
made  to  last  a  sufficient  length  of  time  to  answer  all  purposes.  I  have 
had  the  run  of  some  seventy  consecutive  herniae  with  formalin  gut  with- 
out suppuration.  Even  after  extensive  hernia  operations  of  great 
severity  I  have  used  the  formalin  gut  with  the  best  results.  An  inter- 
esting point  came  to  my  notice  within  the  last  two  years.  A  well- 
known  advocate  of  non-absorbable  sutures  was  appointed  to  a  hospital 
with  which  I  am  connected,  and  he  was  soon  a  convert  to  the  absorb- 
able suture.  What  converted  him,  I  am  sure,  was  a  comparison 
between  his  work  and  our  own. 

I  disagree  with  the  statement  that  the  position  of  the  incision  has 
little  to.  do  with  the  resulting  hernia.  Dr.  Moore  states  that  if  the 
incision  is  properly  sutured  the  results  are  good  ;  but  I  think  the  posi- 
tion of  the  incision  and  the  amount  of  injury  done  to  the  nerves  and 
vessels  of  the  region  have  much  to  do  with  the  resulting  hernia.  We 
are  all  familiar  with  the  right  inguinal  hernise  that  sometimes  follow 
appendicitis  operations,  and  have  all  seen  a  number  of  such  cases.  I 
think  the  reason  is  clear,  /.  <?.,  that  the  atrophy  of  the  tissues  resulting 
from  the  nerve  injury  is  accountable  for  the  herniae.  The  atrophy  of 
the  rectus  following  incision  into  the  linea  semilunaris  is  well  known 
as  is  the  atrophy  following  the  cutting  off  of  the  blood-supply.  I 
know  of  several  cases  of  atrophy  of  the  muscles  of  the  face  following 
ligation  of  the  carotid,  and  I  believe  that  the  planning  of  the  incision 
so  as  to  reduce  to  a  minimum  the  nerve  and  vessel  injury  is  of  the 
greatest  possible  importance.  The  normal  lines  of  incision  should  be 
followed  as  closely  as  possible,  such  as  the  midline  muscle  ;  splitting 
incision  for  the  appendix  ;  the  incision,  usually  made  in  the  division  of 
the  rectus,  and  the  posterior  incision  to  avoid  injury  to  the  intercostal 
nerve  and  the  lumbar  vessels.  In  case  of  operations  such  as  those  on 
the  liver  and  spleen,  in  which  we  do  not  choose  one  of  these  normal 
lines,  we  should  so  plan  our  incision  as  to  reduce  to  a  minimum  the 
danger  of  nerve  and  vessel  injury.     Another  point  has  been  developed 


POST-OPERATIVE     HERNIA.  3I3 

by  my  colleague,  and  that  is  the  use  of  the  auto-suture,  which  he  has 
employed  in  a  limited  number  of  cases,  but  especially  in  operations 
upon  the  appendix.  In  the  inguinal  hernia  operation,  instead  of  using 
a  suture,  a  narrow  ribbon  about  one-sixth  of  an  inch  in  width  is 
stripped  off  from  each  side  of  the  division  of  the  aponeurosis.  This 
may  be  made  four  or  five  inches  in  length,  and  with  this  ribbon  the 
conjoined  tendon  and  Poupart's  ligament  are  sutured  together.  Over 
this  the  aponeurosis  and  the  external  oblique  are  closed  with  a  Fowler's 
suture.  After  removal  of  the  Fowler's  suture  no  material  foreign  to 
the  patient  is  left  in  the  wound.  Some  experimental  work  is  now 
being  done  to  determine  the  life-history  of  these  ribbons.  It  would 
seem  to  be  an  ideal  method,  provided  they  live. 

Dr.  Moore.  Referring  to  my  remarks  in  reference  to  the  place  of 
incision,  and  to  Dr.  Sevan's  comment  in  favor  of  following  the  nor- 
mal line,  I  do  not  wish  to  be  understood  as  in  favor  of  deviating  from 
the  normal.  Appendicitis  we  always  have  with  us,  and  inguinal  hernia 
following  appendicitis  is  much  more  common'  than  it  formerly  was. 
It  would  not  be  surprising  if  we  had  some  strange  coincidences. 


FRACTURES  AND  DISLOCATIONS  OF  THE  SPINE. 


By  S.  H.  weeks,  M.D., 

PORTLAND,   MAINE. 


I  HAVE  been  led  to  choose  this  subject  because  several  cases 
have  come  under  my  observation  recently  at  the  Maine  General 
Hospital  and  in  my  own  practice  as  well.  The  doubt  and  un- 
certainty which  have  hitherto  surrounded  the  treatment  of  such 
injuries  can  only  be  cleared  up  by  a  more  careful  study  of  the 
nature  of  such  injuries.  Fractures  and  dislocations  of  the  spine 
are  so  frequently  associated  in  the  same  patient  that  they  are 
now  spoken  of  as  fracture-dislocations. 

Though  dislocation  of  the  spine  apart  from  fracture  is  rare, 
it  nevertheless  does  sometimes  occur.  It  is  almost  wholly  con- 
fined to  the  cervical  region,  occurring  most  frequently  in  the 
lower  half  of  the  neck.  It  may  be  either  unilateral  or  bilateral. 
The  dislocation  is  usually  brought  about  by  hyperflexion,  which 
causes  the  inferior  articular  processes  of  the  vertebra  above  to 
slip  forward  and  upward  on  the  superior  articular  processes  of 
the  vertebra  below. 

This  is  rendered  possible  by  the  tearing  or  separation  of  the 
intervertebral  disk  and  laceration  of  the  surrounding  ligaments. 
The  displacement  of  the  upper  part  of  the  spine  is  almost  in- 
variably forward.  Unilateral  dislocation  is  sometimes  brought 
about  by  extreme  rotation  of  the  neck.  When  this  occurs  the 
head  will  be  turned  toward  the  opposite  side  and  fixed  in  that 
position,  while  the  irregularity  in  the  spine  and  in  the  transverse 
process  will  be  apparent.  According  to  Dennis,  about  20  per 
cent,  of  these  injuries  are  fractures  alone,  about  20  per  cent,  are 
dislocations  alone,  and  about  60  per  cent,  consist  of  both  frac- 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE.       315 

ture  and  dislocation,  and  are  known  under  the  compound  name 
of  fracture-dislocation. 

Though  the  injury  to  the  bones  may  be  extensive,  this  is  the 
least  important  feature  of  the  case. 

As  in  fractures  of  the  skull,  the  injury  to  the  brain  is  vastly 
more  important,  so  in  fracture  of  the  spine  it  is  the  injury  to  the 
cord  which  is  of  such  vital  importance.  These  fractures,  like 
fractures  elsewhere,  may  be  simple,  compound,  or  complicated. 
It  is  claimed  that  the  bodies  are  more  frequently  fractured  than 
the  arches. 

Aside  from  positive  demonstration  by  dissection,  it  would 
seem  almost  impossible  that  the  vertebrae,  bound  together  by 
numerous  articulations  and  powerful  ligaments  and  cartilages, 
could  be  dislocated  without  being  broken.  Abernethy  denied 
the  possibility  of  such  a  dislocation.  But  though  this  accident 
is  exceedingly  uncommon,  a  sufficient  number  of  cases  have  been 
observed  to  establish  the  existence  of  this  injury  beyond  a  shadow 
of  a  doubt. 

Agnew  gives  a  table  of  24  cases  of  cervical  luxation.  Eleven 
of  these  were  verified  by  a  post-mortem  examination.  The 
cervical  region,  in  consequence  of  the  degree  of  movement  ex- 
isting between  its  vertebrae,  and  also  the  superficial  character  of 
the  articulating  processes,  furnishes  the  largest  number  of  ver- 
tebral dislocations.  The  region  embraced  between  the  fourth 
and  sixth  cervical  vertebrae,  inclusive,  seems  to  be  exception- 
ally vulnerable. 

A  dislocation  may  occur  at  any  of  the  articulations  between 
the  second  cervical  and  first  dorsal  vertebrae.  The  direction  of 
the  displacement  is  generally  forward — that  is,  the  vertebrae 
below  the  one  displaced  remain  fixed,  while  all  the  vertebrae 
above  are  carried  in  an  anterior  direction.  The  manner  in  which 
these  dislocations  occur  would  seem  to  show  that  for  their  pro- 
duction it  is  necessary  that  great  violence  should  be  applied 
either  to  the  head  while  it  is  bent  forward  toward  the  breast,  or 
directly  to  the  back  of  the  neck.  In  the  unilateral  or  one-sided 
displacement  the  force  is  supposed  to  act  more  on  one  side — 
the  affected  side — than  on  the  other,  as  this  luxation  may  result 


3  1 6  WEEKS, 

from  the  spine  being  violently  twisted.  In  addition  to  the  lacer- 
ation of  the  ligaments  and  cartilages  the  cord  itself  may  be 
contused,  crushed,  or  even  severed.  Blood  is  also  extravasated 
both  within  and  without  the  spinal  canal.  The  luxations  which 
occur  above  the  second  cervical  vertebra  are  the  occipito-atloid 
and  the  atlo-axoid.  In  the  three  dislocations  of  the  occipito- 
atloidean  articulation  which  have  been  reported  the  injury  was 
produced  by  violence  applied  to  the  back  of  the  head  or  neck. 
In  the  first  case  (that  given  by  M.  Hassus)  a  bale  of  hay  fell 
from  a  height,  striking  upon  the  back  of  the  neck  a  man  whose 
head,  at  the  time  of  the  accident,  was  bent  over  upon  the  breast. 
In  the  second  case,  recorded  by  M.  Palletta,^  the  luxation  was 
the  result  of  a  fall,  in  which  the  back  of  the  man's  head  most 
probably  first  struck  the  ground.  In  the  third  (M.  Bouisson's) 
case  the  patient  was  a  boy,  who  had  been  crushed  under  a 
wagon.  In  each  case  the  injury  proved  fatal.  The  lesions  in 
all  three  of  these  cases  were  different.  In  the  first  there  was 
an  almost  complete  separation  of  the  condyles  of  the  occipital 
bone  from  the  cup-shaped  cavities  of  the  atlas,  with  laceration 
of  the  vertebral  vessels.  In  the  second,  the  atlas,  though  dis- 
placed, was  not  wholly  separated  from  the  occipital  bone  ;  and 
in  the  third,  the  dislocation  was  unilateral,  the  right  half  of  the 
posterior  arch  of  the  atlas  being  forced  against  the  medulla 
oblongata. 

Atlo-axoid  Dislocations.  The  peculiar  nature  of  the  artic- 
ulation between  the  atlas  and  axis,  admitting  of  extensive  rota- 
tion, renders  it  particularly  liable  to  injury  from  violent  and 
extreme  twists  of  the  head,  or  from  similar  movements  of  the 
body  when  the  head  is  flexed. 

Dislocation  of  the  atlo-axoid  articulation  may  take  place  in 
several  ways.  When  the  odontoid  process  is  broken  the  atlas 
may  slide  backward  from  the  axis,  carrying  with  it  the  process, 
and  crowding  the  upper  part  of  the  spinal  cord.  Or  the  odon- 
toid ligament  may  be  ruptured,  together  with  some  fibres  of 
the  transverse  portion,  a  lesion  which  will  allow  the  odontoid 

•   Cooper's  Surgical  Dictionary. 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE.       317 

process  of  the  axis  to  slip  beneath  it,  even  though  the  transverse 
hgament  may  remain  unbroken.  Again,  the  atlas  may  be 
rotated  upon  the  axis  to  a  degree  which  will  cause  a  rupture  of 
the  articular  ligaments  and  a  displacement  in  which  the  atlas 
will  rest  obliquely  across  the  axis,  the  lower  articulating 
process  of  the  atlas  being  in  front  of  and  the  other  atloidean 
process  behind  the  axoid  process.  And  lastly,  the  dislocation 
may  be  limited  to  the  articulating  process  of  one  side.  Atlo- 
axoid  dislocations  are  the  result  of  falls  upon  the  head,  strokes 
or  blows  upon  the  back  of  the  neck,  sudden  and  extreme  twists 
of  the  head,  or  twists  of  the  body  when  the  head  is  held  in  a 
fixed  position.  It  was  probably  in  the  last-mentioned  way  that 
the  axis  was  displaced  from  the  atlas,  causing  the  instantaneous 
death  of  a  child  while  being  raised  by  the  head,  and  struggling 
to  release  itself,  in  the  case  reported  by  Petit. 

Dislocations  of  the  Dorsal  Vertebr.^.  The  secure  man- 
ner in  which  the  dorsal  vertebrae  are  locked  together,  the  great 
strength  of  the  intervertebral  cartilages  and  ligaments,  and  the 
extent  of  their  articulating  surfaces,  combine  to  render  uncom- 
plicated luxation  of  these  bones  a  matter  of  great  difficulty. 
Very  generally  their  displacement  is  associated  with  a  fracture, 
producing  what  is  now  termed  fracture-dislocation.  This  was 
the  condition  in  most  of  the  13  cases  collected  by  Malgaigne,  the 
verity  of  which  was  established  by  dissection  after  death.  The 
vertebrae  in  the  lower  part  of  the  dorsal  region  are  those  which 
suffer  most,  as  the  flexibility  of  the  spine  in  this  locality  renders 
it  more  vulnerable  than  at  any  point  below  the  cervical  region. 
This  is  well  illustrated  by  the  fact  that  of  the  13  dislocations 
alluded  to  above,  7  occurred  between  the  ninth  dorsal  and  the 
first  lumbar  vertebra. 

These  injuries  are  usually  caused  by  extreme  flexion  of  the 
spine  conjoined  with  the  direct  application  of  great  force. 

The  displacement  may  be  forward  (the  usual  position),  back- 
ward, or  lateral. 

Symptoms  of  Dislocation  of  the  Cervical  Vertebr/e. 
Though  in  many  instances  there  must  remain  some  doubt  as  to 
the  exact  nature  of  the  injury,  yet  in  well-marked  cases  of  this 


3  1 8  WEEKS, 

luxation  the  head  assumes  a  certain  position,  dependent  upon 
the  direction  of  the  displacement — that  is,  it  will  be  flexed  upon 
the  breast  when  the  dislocation  is  backward,  extended  or  carried 
backward  when  the  luxation  is  forward,  and  turned  to  one  side 
or  the  other  when  it  is  a  lateral  luxation.  A  break  in  the  line 
of  the  spinous  processes  may  also  be  detected,  the  dislocated 
vertebra  and  all  above  it  being  found  either  in  front  of,  behind, 
or  to  one  side  of  those  below  the  seat  of  injury.  The  same 
want  of  regularity  which  is  noticed  in  the  position  of  the  spinous 
processes  may  be  seen  to  exist  to  some  extent  also  in  the 
anterior  surfaces  of  the  bodies  of  the  vertebrae  by  examining 
the  posterior  wall  of  the  pharynx.  Both  in  dislocation  and 
fracture-dislocation  of  the  cervical  vertebrae,  paralysis,  more  or 
less  complete,  follows  the  injury,  affecting  all  the  parts  below 
the  seat  of  injury.  Death,  after  a  lesion  of  this  nature,  may 
follow  almost  instantly,  especially  when  the  luxation  is  above 
the  origin  of  the  phrenic  nerve,  or  it  may  be  delayed  for  a  few 
days,  rarely  exceeding  two.  Of  1 1  cases  which  appear  in  the 
table  above  alluded  to,  and  were  verified  by  post-mortem  exam- 
ination, all  died  at  periods  ranging  from  twenty-four  hours  to 
eleven  days,  except  in  a  single  instance,  when  the  patient  lived 
fifteen  days.  The  symptoms  of  an  atlo-axoid  dislocation  must 
necessarily  be  very  vague  and  uncertain. 

Should  the  head  be  found  twisted  to  one  side  and  incapable 
of  rotation,  with  a  bent  state  of  the  neck,  and  if  it  were  known 
that  a  sufficient  cause  of  dislocation  had  been  applied  there 
would  be  presumptive  evidence  of  a  unilateral  displacement, 
provided,  however,  no  deformity  could  be  felt  at  a  lower  part  of 
the  cervical  spine.  Unilateral  dislocation  is  sometimes  brought 
about  by  extreme  rotation  of  the  neck.  When  this  occurs  the 
head  will  be  turned  toward  the  opposite  side  and  fixed  in  that 
position,  while  an  irregularity  in  the  spines  and  in  the  trans- 
verse processes  will  be  present.  Pressure  upon  the  nerves  rising 
between  the  displaced  vertebrae  gives  rise  to  peripheral  pain 
and  numbness.  Varying  degrees  of  paralysis,  both  of  motion 
and  sensation  up  to  the  level  of  the  lesion,  will  result  from  com- 
pression of  the  spinal  cord,  and  will  depend  upon  the  amount 


FRACTURES     AND     DISLOCATIONS    OF    THE    SPINE.       319 

of  injury  inflicted.  When  the  dislocation  is  unilateral  the  cord 
may  escape  injury,  or  the  damage  to  it  be  but  slight.  When 
the  paralysis  is  delayed  for  days  it  will  probably  be  due  to  an 
inflammatory  effusion  of  serum  or  lymph,  or  to  inflammatory 
softening  of  the  cord. 

Treatment.  In  considering  the  matter  of  treatment  let  us 
inquire  what  cases  require  operation  and  in  what  cases  is  sur- 
gical interference  cotitraindicated.  In  the  treatment  of  fracture- 
dislocation  I  believe  the  surgeon  should  perform  laminectomy 
in  every  case,  if  the  condition  of  the  patient  is  such  as  to  justify 
any  operation,  regarding  the  operation  in  the  first  instance  as  an 
exploratory  one. 

The  hope  of  restoration  of  function  in  those  cases  in  which 
the  cord  is  not  irretrievably  injured  depends  on  the  promptitude 
with  which  the  cause  of  compression  is  removed ;  and,  how- 
ever small  the  number  of  cases  may  be  in  which  benefit  is  to  be 
looked  for,  I  hold  that  even  those  few  justify  one  in  immediate 
operation.  Laminectomy  is  not  a  difficult  operation,  since  the 
soft  parts  are  always  found  torn  and  quite  detached  from  the 
bone,  and  the  introduction  of  cutting  instruments  or  forceps 
under  the  lamina  is  very  easy  from  the  displacement  present. 

When  an  exploratory  laminectomy  has  been  undertaken  in 
fracture-dislocation,  and  such  displacement  found  that  the  re- 
moval of  the  neural  arch  does  not  suffice  to  relieve  the  pressure 
on  the  cord  entirely,  the  operation  can  be  extended  to  the 
articular  processes,  so  that  manipulation  in  the  wound,  com- 
bined with  extension  and  rotation,  may  succeed  in  reducing  the 
dislocation  and  restoring  the  normal  line  of  the  spinal  column. 
Chipault  advocates  early  interference  if  an  operation  is  to  be 
done,  owing  to  the  fact  that  degenerative  changes  of  the  cord 
take  place  within  twenty-four  hours,  as  has  been  shown  by 
experiments  on  animals  and  by  autopsies.  Laurestine  believes 
that  even  if  there  is  incontinence  of  urine  and  feces,  with  cys- 
titis and  bed-sores,  an  operation  is  justifiable,  as  recovery  cannot 
be  expected  without  operation.  Mr.  Horsley  is  definitely  in 
favor  of  an  operation  in  all  cases  where  there  are  symptoms 
which  would  show  pressure  upon  the  cord.     Burrell  analyzed 


3  20  WEEKS, 

i68  cases,  and  advocates  operation  in  the  first  twenty-four  hours 
in  all  cases  of  fracture,  even  including  those  in  the  cervical 
region.  Thornburn  has  reported  6i  cases  of  operation,  with  35 
deaths;  Chipault  has  collected  95  cases,  with  38  deaths;  Lloyd 
has  found  mortality  of  57  per  cent,  after  operation.  The  oper- 
ation consists  of  laminectomy  for  the  purpose  of  removing  from 
the  cord  the  pressure  of  extravasated  blood  or  loose  spiculse  of 
bone.  The  danger  from  an  operation  increases  with  the  height 
of  the  lesion.  Reider  reports  the  case  of  a  tiler  who  fell  from 
a  second  story.  There  were  somnolence,  paraplegia,  and  anjes- 
thesia  of  the  lower  extremities  ;  the  fifth  and  sixth  dorsal  spines 
were  prominent;  vesication  soon  began  to  form. 

Sixteen  hours  after  the  accident  the  fractured  spinous  proc- 
esses and  laminae  were  resected,  removed,  relieving  the  com- 
pression of  the  spinal  cord,  which  was  already  somewhat  soft- 
ened. The  symptoms,  with  the  exception  of  the  paralysis  of 
the  bladder,  at  once  improved,  and  on  the  sixth  day  the  urine 
and  feces  were  discharged  voluntarily.  A  plaster-jacket  was 
applied,  and  four  months  later  the  patient  attempted  to  walk. 
Two  months  afterward  he  still  had  a  slow  and  spastic  gait, 
using  a  stick. 

A  better  result  was  obtained  in  a  case  reported  by  Huss,  in 
which  a  man,  aged  thirty  four  years,  had  fallen  a  distance  of 
twelve  feet,  producing  a  fracture-dislocation  at  the  junction  of 
the  dorsal  and  lumbar  region,  with  paraplegia,  paralysis  of  the 
rectum  and  bladder,  and  an  enormous  slough  over  the  sacrum. 

A  month  after  the  accident  the  arches  of  the  tenth  and 
eleventh  dorsal  vertebrae  were  removed,  the  cord  was  found 
angulated,  the  dura  was  not  distended,  and  was  left  unopened. 
Immediate  relief  was  experienced  ;  all  the  symptoms  subsided, 
and  two  or  three  months  later  the  patient  was  able  to  walk 
perfectly  well,  and  the  spinal  column  presented  no  deformity. 

A  very  interesting  case  of  laminectomy  for  fracture-disloca- 
tion, with  a  good  result,  is  reported  by  Knox.  The  patient  was 
a  boy,  aged  thirteen  years,  injured  in  a  pit  by  a  "  cage  "  falling 
upon  him  and  doubling  him  up.  The  eleventh  dorsal  vertebra 
projected  distinctly  ;  both  sensation  and  motion  were  lost  in  the 


FRACTURES     AND     DISLOCATIONS    OF    THE    SPINE.       32I 

lower  extremities,  but  the  bladder  was  under  control.  On  the 
second  day  the  spinal  column  was  laid  bare  at  the  seat  of  injury, 
and  the  body  of  the  eleventh  dorsal  vertebra  was  found  broken 
across  ;  the  upper  articular  processes  were  also  broken  ;  there  was 
displacement  backward,  with  some  rotary  complication.  The 
laminae  of  the  tenth  vertebra  were  sawed  through,  but  the  dura 
was  not  opened ;  careful  extension  was  made,  and  the  fragments 
pushed  into  proper  place.  Pulsation  was  at  once  restored  in 
the  cord,  and  the  next  day  sensation  was  perfect  in  the  lower 
limbs ;  but  the  power  of  movement,  except  of  the  toes,  was  not 
regained  for  nearly  two  months. 

At  the  time  of  the  report — almost  a  year  after  the  accident — 
the  boy  was  able  to  stand  erect,  and  even  to  take  a  few  steps 
without  any  support ;  the  movements  of  the  ankle  and  tarsal 
joints  were  still  very  limited.  Knox  thinks,  and  it  would  seem 
with  reason,  that  the  injury  sustained  was' chiefly  in  the  anterior 
columns  of  the  cord,  about  the  middle  or  lower  part  of  the 
lumbar  enlargement.  The  recovery  of  movement,  as  well  as  of 
the  size  and  firmness  of  the  muscles,  took  place  gradually  from 
above  downward. 

A  successful  operation  for  fracture  of  the  third  lumbar  ver- 
tebra, the  Cauda  equina  being  compressed  by  callus,  which  was 
removed  with  difficulty  after  stripping  away  of  the  laminae  of 
the  second,  third,  and  fourth  lumbar  vertebrae,  is  recorded  by 
Starr.  The  operation  was  performed  a  year  after  the  occur- 
rence of  the  injury;  at  the  time  of  the  report  the  man  had  a 
fair  control  of  the  rectum  and  bladder,  the  paralysis  had  almost 
disappeared,  and  anaesthesia  alone  remained.  Lane  reports  a 
case  in  which  an  operation  was  performed  for  a  fracture  dislo- 
cation of  the  spine.  The  symptoms  came  on  gradually  after  the 
injury  and  rapidly  increased  in  severity.  It  was  found  that  the 
tenth  dorsal  vertebra  was  displaced  forward  and  slightly  down- 
ward, so  that  the  cord  was  compressed  between  the  laminic  of 
the  tenth  and  the  body  of  the  eleventh  dorsal  vertebrae  The  dis- 
placement was  not  very  great,  so  that  the  cord  was  apparently 
squeezed  rather  than  crushed.  The  interspinous  ligament  was 
torn  through.     After  great  difficulty  the  tenth  dorsal  vertebra 

Am  Surg  21 


322  WEEKS, 

was  brought  back  into  its  normal  position.  This  was  effected 
partly  by  overextending  the  dorsal  spine  and  partly  by  traction 
exerted  upon  the  spinous  process  by  lion  forceps,  and  the 
spinous  processes  were  tied  together.  Thirteen  days  later  he 
appeared  to  have  recovered  complete  control  over  his  legs. 
The  spinous  processes  were  in  good  position  over  the  same 
transverse  plane.  The  reflexes  were  then  normal.  The  patient 
kept  constantly  rolling  about,  and  complete  paraplegia  soon 
developed.  The  wound  was  explored,  when  the  vertebrae  were 
found  to  be  displaced  laterally  upon  one  another,  and  the  cord 
was  completely  divided.  This  unfortunate  result  was  due  to  the 
extremely  troublesome  character  of  the  patient,  whom  it  was 
found  impossible  to  control  by  any  means. 

Wyeth  reports  the  histories  of  three  cases  of  fracture  of  the 
spine  in  which  he  had  operated.  The  first  was  that  of  a  man, 
twenty-two  years  of  age.  In  1890  the  patient  was  struck  by 
the  pilot  of  a  locomotive,  and  fractured  the  second  lumbar 
vertebra,  and  had  been  immediately  paralyzed  from  that  point 
down. 

Two  years  later  the  eleventh  and  twelfth  lumbar  arches  were 
removed,  and  found  the  cord  compressed  by  dislocation  of  the 
body  of  the  second  lumbar  vertebra;  six  hours  later  improve- 
ment had  begun,  and  now,  the  patient,  though  far  from  being 
perfectly  well,  was  able  to  get  about,  and  had  been  greatly 
improved  by  the  operation. 

Vincent  reports  three  cases  in  which  he  operated  on  the  spine 
for  penetrating  gunshot  wound  with  injury  to  the  cord.  In  the 
first  case,  which  was  one  of  injury  to  the  first  lumbar  vertebra, 
removal  of  fragments  of  bone  and  of  the  bullet  from  the  spinal 
canal  was  followed  by  complete  recovery.  In  the  other  two 
cases — each  of  penetrating  wound  in  the  lower  part  of  the 
dorsal  region,  with  laceration  of  the  cord  and  its  membranes — 
similar  treatment  was  followed  by  death,  in  one  on  the  eleventh 
and  the  other  on  the  fourteenth  day. 

Hammond  says  that  pressure  prolonged  for  any  length  of 
time  invariably  causes  degeneration,  both  ascending  and  de- 
scending, of  the  different  tracts   of  the  cord.     Relief  of  the 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE.       323 

pressure  is  not  followed  by  any  diminution  of  the  degeneration. 
But  relief  of  the  pressure  prevents  the  process  of  degeneration 
from  beginning.  Hence,  the  surgeon  should  operate  as  soon 
as  possible  after  the  injury  to  the  cord  has  been  received. 
Lloyd,  after  a  study  of  103  cases,  agrees  with  Horsley,  that 
operation  should  be  undertaken  at  once  "  in  all  cases  when  dis- 
placement or  crepitus  indicates  compression,  and  when  exten- 
sion directly  after  the  accident  clearly  fails  to  reduce  the 
deformity,"  provided  there  are  symptoms  present  which  indi- 
cate interference  with  the  function  of  the  cord.  In  other  cases, 
the  operator  should  wait  until  the  shock  following  the  injury 
has  been  overcome.  During  this  time,  however,  the  patient's 
condition  should  be  most  carefully  watched,  and  the  first  indi- 
cation of  any  symptoms  pointing  to  the  extension  of  the  inter- 
ference with  the  function  of  the  spinal  cord,  whether  that 
interference  be  due  to  hemorrhage  or  myelitis  from  com- 
pression. 

A  Report  of  One  of  My  Own  Cases. 

August  29,  1900,  Mr.  C.  P.,  aged  seventy  years,  fell  from  a  ladder, 
a  distance  of  about  twelve  feet,  striking  on  his  right  shoulder  and 
right  side  of  the  head.  He  was  rendered  partially  unconscious,  and 
while  in  this  condition  was  carried  into  the  house,  when  it  soon 
became  apparent  that  he  had  sustained  some  serious  lesion  somewhere 
in  the  cervical  region.  The  head  was  thrown  slightly  backward, 
turned  sharply  to  the  right,  and  before  operation  held  firmly  in  this 
position.  The  left  upper  extremity  was  paralyzed  as  to  motion  ;  sen- 
sation was  apparently  good.  Motion  in  right  upper  extremity  fairly 
good ;  motion  in  lower  extremity  also  fairly  good.  He  was,  however, 
unable  to  pass  his  urine,  the  use  of  the  catheter  being  required.  There 
was  great  pain  in  the  left  arm  and  hand.  Nine  days  after  the  injury 
I  saw  him  in  consultation  with  the  attending  physicians,  and  found 
the  condition  which  I  have  described  above,  and  also  found  a  de- 
formity of  the  cervical  spine  at  about  the  fourth  vertebra ;  it  seemed 
like  a  dislocation,  and  as  if  there  were  a  fracture  with  a  fragment  of 
bone  pressing  upon  or  had  injured  the  spinal  nerve-supply  to  the 
left  upper  extremity.  An  operation  was  thought  advisable  to  see  if 
the  condition  could  be  improved. 


324  WEEKS, 

The  next  day,  September  8,  1900,  I  made  the  operation.  The 
laminge  of  the  third  and  fourth  cervical  vertebrae  were  found  broken 
and  depressed.  These  were  removed  and  the  cord  relieved  of  all 
pressure  so  far  as  possible,  and  the  wound  closed  without  drainage. 
The  position  of  the  patient  during  the  operation  was  upon  the  face. 
As  I  was  closing  the  wound  the  patient  became  badly  cyanosed  and 
the  pulse  feeble.  He  was  turned  upon  the  back,  J^  grain  of  strychnine 
given  hypodermically,  and  he  was  soon  breathing  regularly,  and  no 
further  trouble  was  experienced.  The  seventh  day  after  the  operation 
the  patient  had  a  slight  chill,  became  cyanosed,  with  a  weak  pulse. 
He  complained  of  numbness  of  the  lower  extremities,  especially  the 
left  side.  Strychnine  (g?^  of  grain)  was  given  subcutaneously,  and 
repeated  in  half  an  hour.  In  the  afternoon  of  the  same  day  his  tem- 
perature was  102.4° ;  respiration,  28;  pulse,  108.  The  dressings  were 
removed  for  the  first  time,  and  it  was  found  that  the  wound  had  healed 
by  first  intention.  The  lower  stitches  were  removed,  thinking  there 
might  be  some  retained  fluids  that  had  caused  the  sudden  rise  in  tem- 
perature. Some  bloody  serum  escaped  from  the  wound.  Soon  after 
this  the  temperature  fell  to  100.4°.  The  next  day  the  bowels  were 
freely  moved  with  Hunyadi  water,  and  the  temperature  became  nor- 
mal. During  this  attack  the  left  leg  became  partially  paralyzed. 
Strychnine  (-^-^  of  grain)  and  quinine  (2  grains)  were  given  three  times 
in  the  day.  The  wound  was  irrigated  and  dressed  every  day  with  a 
strip  of  sterilized  gauze  for  drainage.  I  am  satisfied  that  it  would  have 
been  better  had  I  put  in  a  gauze  drain  at  the  time  of  the  operation,  as 
the  man  was  large  and  muscular,  and  the  wound  deep  and  hard  to 
close  without  leaving  spaces  between  the  divided  tissues.  At  the  end 
of  the  sixth  week  from  the  time  of  the  operation  the  wound  was  entirely 
healed.  The  fourth  week  the  patient  had  an  attack  of  cystitis.  This 
was  reduced  by  irrigation  of  the  bladder  twice  a  day  with  normal  salt 
solution,  with  5  grains  of  salol  four  times  a  day. 

The  fifth  week  the  patient  was  able  to  sit  up  in  a  chair  three  or  four 
hours  each  day.  There  was  good  motion  of  the  head,  lower  limbs, 
and  right  arm ;  but  no  motion  in  the  left  arm.  At  the  end  of  the 
sixth  week  he  was  able  to  sit  up  from  four  to  six  hours  each  day,  and 
was  also  able  to  take  a  few  steps  with  assistance.  At  this  time  he  had 
a  little  motion  in  the  fingers  of  the  left  hand. 

From  a  letter  received  from  his  son,  and  signed  by  the  patient  him- 
self, dated  November  15,  1900,  two  and  a  half  months  after  the  injury, 
I  quote  the  following  :   "  My  father's  condition  now,  as  compared  with 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE,       325 

that  before  the  operation,  is  an  improvement  of  75  per  cent.  He  has 
a  good  appetite ;  can  eat  anything  he  wants  ;  has  gained  a  good  deal 
in  strength  ;  can  walk  short  distances  by  being  supported  on  either 
side.  His  left  leg  bothers  him  some,  and  both  legs  are  somewhat 
weak.  The  right  hand  and  arm  are  nearly  normal.  Can  write  his 
name  legibly.  There  has  been  some  improvement  in  the  motion  of 
left  hand  and  arm ;  can  move  forearm  some  by  having  it  supported. 
His  greatest  trouble  is  pain  in  his  left  shoulder,  arm,  and  hand.  He 
can  support  his  head  and  turn  it  fairly  well  in  either  direction  ;  wound 
in  neck  entirely  healed,  and  lameness  in  cords  and  muscles  seems  to 
be  growing  less  daily.  His  head  was  turned  sharply  to  the  right  before 
the  operation  and  firmly  held  in  that  position.  The  action  of  the 
bladder  is  now  normal." 

Technique  of  Laminectomy,  The  greatest  possible  care 
should  be  taken  to  have  the  operation  thoroughly  aseptic.  No 
operation  demands  greater  care  in  all  its  details. 

The  shock  of  the  operation  is  almost  always  severe,  hence 
every  precaution  must  be  taken  to  avoid  it, 

Mr.  Horsley  has  called  attention  to  five  special  dangers. 
First,  that  of  hemorrhage.  This  is  always  considerable  in 
amount ;  but  by  means  of  haemostatic  forceps,  and  by  pressure 
by  means  of  gauze  and  sponges  dipped  in  hot  water,  it  may 
easily  be  controlled.  Second,  difficulty  in  clearing  the  spinal 
canal.  With  care  and  patience  the  difficulty  can  be  over- 
come. Third,  physical  difficulties  in  treating  the  fractured  ver- 
tebrae. In  many  cases  the  vertebrae  are  hopelessly  fractured 
and  displaced,  and  cannot  be  dealt  with  satisfactorily.  Unfortu- 
nately, we  are  not  always  or  even  often  able  to  judge  of  the 
severity  of  the  fracture  until  it  has  been  revealed  by  the  opera- 
tion. Fourth,  the  hopeless  nature  of  the  injury  to  the  spinal 
cord.  In  the  majority  of  cases  of  fracture-dislocation  the  cord 
has  been  injured  beyond  the  possibility  of  repair.  Fifth,  the 
danger  of  septic  infection. 

With  the  observation  of  modern  aseptic  surgery  there  should 
not  be  much  danger  of  septic  infection,  excepting  in  compound 
fractures  where  infection  has  taken  place  before  the  surgeon 
sees  it,  or  in  those  cases  in  which  a  fistula  results  from  too 


326  WEEKS, 

long  use  of  the  drainage-tube  ;  as  a  rule,  this  should  be  re- 
moved within  twenty-four  or  forty-eight  hours.  Sixthly,  to 
these  dangers  White  has  very  justly  added  the  danger  of  anaes- 
thesia in  the  prone  position,  the  abdominal  muscles  being  par- 
alyzed. This  is  a  very  real  danger,  and  was  well  illustrated  in 
one  of  my  own  cases,  in  which  the  patient  stopped  breathing 
and  came  near  dying  before  the  operation  was  completed.  The 
depressed  fragments  of  bone  had  been  removed,  the  cord  liber- 
ated, and  I  was  in  the  act  of  closing  the  wound  when  respira- 
tion suddenly  ceased.  The  wound  was  immediately  covered 
with  sterilized  gauze,  he  was  turned  on  his  side,  the  tongue 
pulled  forward,  and  soon  restoration  was  restored.  The  sewing 
up  and  appliance  of  dressing  were  made  with  the  patient  on  his 
side.  No  further  trouble  was  experienced,  and  my  patient  made 
a  good  recovery.  The  instruments  which  will  be  needed  are 
hsemostatic  forceps  (two  dozen),  scalpels,  rongeur  and  other 
bone  forceps,  raspatories,  and  a  half-inch  trephine,  retractors, 
needle  and  needle-holder.  It  is  claimed  by  some  that  the 
patient  should  be  placed  in  Sims'  position,  but  I  have  always 
placed  my  patients  in  the  prone  position,  having  the  face 
brought  to  the  edge  of  the  table. 

A  hypodermic  syringe  charged  with  -^^^  grain  of  strychnine 
should  be  at  hand.  The  patient  should  be  well  protected  by 
blankets  and  hot-water  bottles,  care  being  taken  not  to  burn 
the  patient,  which  has,  unfortunately,  happened  several  times 
in  my  experience.  Everything  being  ready,  an  incision  is 
made  in  the  median  line  of  the  back,  directly  over  the  spinous 
processes,  from  four  to  six  inches  long,  and  as  much  longer  as 
the  extent  of  the  operation  demands.  The  resection  should  not 
be  limited  to  one  or  two  arches,  but  should  be  a  large  one, 
often  involving  the  removal  of  five  or  six  arches.  I  have 
always  found  a  simple  linear  incision  sufficient.  Chipault  has 
pointed  out  that  in  a  normal  spine  the  arches  are  of  little  value 
in  producing  solidity  of  the  spine,  but  that  when  the  bodies  are 
gone,  as  in  Pott's  disease,  the  arches  replace  the  bodies  to  some 
extent  in  securing  a  solid  spine. 

The  muscles  are  first  separated  from  the  arches  on  one  side; 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE.       327 

this  is  packed  with  gauze  to  control  hemorrhage,  and  the  mus- 
cles on  the  other  side  are  separated  from  the  bones,  and  this  in 
turn  is  packed. 

By  the  time  the  second  dissection  has  been  made  and  the 
wound  packed  the  first  will  be  ready  for  the  final  clearing  of 
the  arches.  Mr.  Horsley  claims  that  the  separation  of  the 
muscles  from  the  arches  should  not  be  done  with  a  blunt 
raspatory,  but  by  clean  cuts  of  the  knife.  This  is  important, 
because  the  spinal  muscles  consist  largely  of  slips  running 
short  distances,  and  any  blunt  instrument  leaves  the  tissues  in 
tatters  which  are  likely  to  undergo  necrosis.  When  the  mus- 
cles have  been  well  separated  from  the  arches  with  the  knife  a 
raspatory  can  then  be  used  with  advantage  to  scrape  away  the 
remaining  muscular  tissue  which  still  adheres  to  the  bone,  and 
thus  obtain  a  clear  field  of  operation.  During  the  first  stage  of 
the  operation  the  hemorrhage  is  very  free.  Large  arteries  may 
be  seized  by  an  assistant  with  haemostatic  forceps,  but  the 
operator  should  not  waste  any  time  by  attempting  to  do  so. 

The  more  quickly  he  exposes  the  bone  and  packs  the  wound 
the  less  will  be  the  amount  of  blood  lost.  I  have  usually  de- 
ferred the  final  cleansing  of  the  arches  until  after  the  hemor- 
rhage has  been  arrested.  To  make  an  opening  into  the  spinal 
canal  the  trephine  may  be  used,  one  edge  being  placed  close 
against  the  spinous  process,  lest  the  intravertebral  nerves 
should  be  wounded  by  the  penetration  of  the  trephine.  The 
interspinous  ligaments  are  best  divided  by  a  pair  of  blunt- 
pointed  scissors,  there  being  less  danger  of  wounding  the  cord 
and  its  membranes  than  when  the  knife  is  used.  Having  iso- 
lated one  of  the  spinous  processes,  it  may  be  quickly  removed, 
together  with  a  part  of  one  of  the  arches,  by  the  rongeur  for- 
ceps. As  soon  as  an  opening  is  made  into  the  canal  the  arches 
may  be  quickly  removed  by  means  of  ordinary  bone-forceps  or, 
still  better,  by  rongeur  forceps,  such  as  are  used  for  linear  crani- 
otomy. The  arches  being  removed,  a  somewhat  thick  layer  of 
fatty  tissue  lies  over  and  obscures  the  membranes  of  the  cord. 
In  it  lies  a  plexus  of  veins  which  sometimes  give  some  trouble, 
but  the   hemorrhage   is  easily  controlled  by   gauze  pressure. 


328  WEEKS, 

The  fatty  tissue  is  best  treated  by  carefully  dividing  it  in  the 
median  line,  pressing  it  to  each  side,  and  packing  with  small 
strips  of  sterilized  gauze. 

The  dura  should  now  be  carefully  examined  to  see  whether 
it  pulsates.  If  there  is  no  pulsation  it  is  generally  due  to  ad- 
hesions or  some  other  cause  of  interference  with  the  continuity 
of  the  subdural  space.  If  there  is  blood  within  the  dura  the 
membrane  will  present  a  bluish  or  purplish  hue;  if  pus,  yellow- 
ish. If  a  tumor  is  present  or  there  is  any  increase  in  the  quan- 
tity of  cerebro-spinal  fluid  the  increased  tension  and  elasticity 
of  the  dura  will  be  perceptible  to  the  touch.  The  membranes 
and  the  cord  may  now  be  carefully  drawn  first  to  one  side  and 
then  to  the  other  by  means  of  an  aneurism  needle  or  any  simi- 
lar instrument,  in  order  to  expose  the  bodies  of  the  vertebrae  for 
observation,  or,  if  necessary,  for  operation.  The  nerves  are 
sufficiently  elastic  to  allow  of  moderate  stretching  as  the  cord 
is  moved  to  one  side  and  then  to  the  other.  Chipault  places 
two  cushions  under  the  abdomen  of  the  patient,  some  distance 
apart,  so  that  the  spine  is  concave  posteriorly,  which  will  facili- 
tate the  displacement  of  the  cord.  Whether  the  dura  should 
be  opened  is  a  more  serious  question  in  the  spine  than  in  the 
brain.  In  the  latter  the  opening  can  be  closed  without  drain- 
age, and  thus  we  can  prevent  the  continuous  escape  of  the 
cerebro-spinal  fluid.  After  an  operation  upon  the  spine  the 
injury  to  the  thick  muscles  will  usually  prevent  primary  union, 
and  so  favor  the  formation  of  a  fistula,  and  the  wound  is  so 
extensive  and  deep  that  drainage  is  usually  required,  and  a 
strip  of  sterilized  gauze  is  the  best,  which  can  usually  be  re- 
moved in  two  or  three  days  or  at  the  time  of  the  first  change 
of  dressing.  The  mere  temporary  escape  of  the  cerebro-spinal 
fluid  is  not  in  itself  dangerous.  I  have  seen  a  large  quantity 
lost  at  the  time  of  the  operation  and  continuously  escape  for 
some  days  afterward  without  any  ill  effects.  But  if  a  fistula 
results,  and  the  cerebro-spinal  fluid  escapes  continuously,  this  is 
a  source  of  annoyance  and  irritation  to  the  surrounding  skin, 
and  requires  constant  redressing,  and  has  one  far  more  serious 
source  of  danger — namely,  that  it  is  almost  impossible  in  re- 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE.       329 

peated  dressings  to  avoid  infection,  which  may  lead  to  menin- 
gitis, myelitis,  and  often  death.  Notwithstanding  these  objec- 
tions, it  is  claimed  by  most  operators  that  the  dura  should 
generally  be  opened.  The  best  result  I  ever  had  was 'in  a  case 
of  fracture-dislocation  in  the  middle  cervical  region,  when  I  did 
not  open  the  dura  because  the  dura  was  so  distended  with  what 
I  believed  to  be  cerebro-spinal  fluid,  and  was  in  such  close  prox- 
imity to  the  brain.  When  the  dura  is  opened  and  the  operation 
completed,  the  opening  in  the  dura  should  be  closed,  if  possible, 
with  a  continuous  catgut  suture  in  order  to  secure  immediate 
union.  If  the  dura  is  not  opened  we  cannot  learn  the  exact 
condition  of  the  subdural  space  and  the  cord  itself. 

Having  opened  the  dura  the  canal  can  be  explored  carefully 
by  an  ordinary  bent  probe.  So,  too,  the  extradural  space 
between  the  dura  and  the  laminae  should  be  explored  in  order 
to  determine  whether  there  are  any  irregularities  or  obstruc- 
tion, fracture,  dislocation,  etc.  If  the  cord  has  been  crushed  or 
injured  by  accident,  any  splinters  of  bone  should  be  removed, 
and  any  considerable  irregularity  due  to  dislocation  or  fracture 
of  the  bodies  of  the  vertebrae  should  be  carefully  removed  by 
the  gouge  or  chisel.  Attempts  have  been  made  by  several  sur- 
geons to  suture  the  cord  itself,  but  without  success.  Leckey 
has  even  gone  so  far  as  to  propose  to  shorten  the  spine  by 
removing  a  part  or  the  whole  of  a  vertebra,  or  portion  of  two 
vertebrae,  by  gouges  or  drills,  a  procedure  which  is  only  men- 
tioned to  be  condemned.  The  nerves,  when  they  have  emerged 
from  the  cord,  are  peripheral  nerves,  and  should  be  treated  by 
suture,  when  divided,  just  as  in  any  other  part  of  the  body. 

Sometimes  it  may  be  better  not  to  suture  the  theca,  but  to 
leave  it  open,  the  purpose  being  to  relieve  the  increased  press- 
ure on  the  cord  from  its  swelling.  No  harm  has  come  from  the 
escape  of  the  cerebro-spinal  fluid  when  the  incision  in  the  dura 
has  been  left  open  ;  no  drain  should  be  inserted  within  the  theca. 
A  wick  of  sterilized  gauze  should  be  placed  in  the  muscular  por- 
tion of  the  wound  to  carry  off"  the  abundant  wound  fluids  of  the 
first  twenty-four  or  forty-eight  hours.  At  the  end  of  this  time 
it  had  better  be  removed. 


330  WEEKS, 

In  closing  the  wound  the  muscles  should  be  approximated 
by  buried  catgut  sutures,  the  skin  sutured  by  silkworm-gut, 
and  the  usual  dressing  applied.  The  position  of  this  patient, 
which  will  be  nearly  dorsal,  happily  favors  drainage. 

After-treatment.  On  account  of  the  free  oozing  of  the 
wound  fluids,  and  sometimes  of  the  cerebro-spinal  fluids,  the 
wound  will  have  to  be  dressed  within  the  first  twelve  hours, 
after  the  first  day  not  usually  more  than  once  in  two  or  three 
days.  At  these  subsequent  dressings  the  strictest  antisepsis 
must  be  observed,  lest  infection  should  follow.  This  is  particu- 
larly necessary  if  there  are  bed-sores,  since  they  produce  foul 
discharges  which  may  infect  the  wound.  If  the  patient  has 
lost  control  of  the  bladder  and  bowels,  which  is  usually  the 
case,  it  being  necessary  to  use  the  catheter,  an  additional  source 
of  infection  exists,  which  will  require  great  watchfulness. 

The  spine  is  best  supported  during  the  healing  process  by 
plaster-of-Paris  dressing  or  by  sand-bags  placed  on  each  side  of 
the  patient.  In  one  of  my  patients  with  a  fracture-dislocation 
of  the  cervical  spine,  above  reported,  the  parts  were  supported 
by  a  sand-bag  on  each  side  of  the  head  and  neck.  The  usual 
precautions  as  to  food  and  drink  must  be  observed,  together 
with  the  use  of  opiates,  for  the  relief  of  pain,  and  such  other 
symptomatic  treatment  as  may  be  indicated. 

Conclusion.  Though  dislocation  of  the  vertebrae  without 
fracture  is  rare,  it  nevertheless  does  sometimes  occur.  Dislo- 
cation without  fracture  is  almost  wholly  confined  to  the  lower 
half  of  the  cervical  region. 

The  dislocation  is  usually  brought  about  by  hyperflexion, 
which  causes  the  inferior  articular  processes  of  the  vertebra 
above  to  slip  forward  and  upward  on  the  superior  articular 
processes  of  the  vertebra  below. 

The  displacement  of  the  upper  part  of  the  spine  is  almost 
invariably  forward. 

About  20  per  cent,  of  these  injuries  are  dislocations  alone, 
about  20  per  cent,  are  fractures  alone,  and  about  60  per  cent, 
are  fracture-dislocations  (Dennis). 


FRACTURES    AND    DISLOCATIONS    OF    THE    SPINE.       33I 

In  these  injuries  the  great  danger  h'es  in  compression  and 
laceration  of  the  cord. 

In  the  dorsal  and  lumbar  regions  the  dislocation  is  very  gen- 
erally associated  with  fracture. 

The  most  prominent  symptom  is  paralysis,  more  or  less  com- 
plete, affecting  all  the  parts  below  the  seat  of  injury. 

Death  may  follow  almost  instantly,  especially  when  the  lux- 
ation is  above  the  origin  of  the  phrenic  nerves.  When  the 
paralysis  is  delayed  for  several  days,  it  will  probably  be  due  to 
an  inflammatory  effusion  of  serum  or  lymph,  or  to  an  inflam- 
matory softening  of  the  cord. 

Treatment.  The  surgeon  should  perform  laminectomy  in 
every  case,  if  the  condition  of  the  patient  is  such  as  to  justify 
any  operation,  regarding  the  operation  in  the  first  instance  as 
an  exploratory  one.  The  hope  of  restoration  of  function  in 
these  cases,  in  which  the  cord  is  not  irretrievably  injured,  de- 
pends upon  the  promptitude  with  which  the  cause  of  compres- 
sion is  removed ;  and  however  small  the  number  of  cases  may 
be  in  which  benefit  is  to  be  looked  for,  even  those  few  justify 
one  in  immediate  operation. 

Laminectomy  is  not  a  difficult  or  dangerous  operation.  The 
greatest  possible  care  should  be  taken  to  have  the  operation 
thoroughly  aseptic.  No  operation  demands  greater  care  in  all 
its  details.  In  making  the  operation,  resection  should  not  be 
limited  to  one  or  two  arches,  but  should  be  a  large  one,  often 
involving  the  removal  of  five  or  six  arches.  The  membranes 
and  the  cords  can  be  carefully  drawn  first  to  one  side,  and  then 
to  the  other  in  order  to  expose  the  bodies  of  the  vertebrae  for 
examination  and,  if  necessary,  for  operation. 

Whether  the  dura  should  be  opened  is  a  more  serious  ques- 
tion in  the  spine  than  in  the  brain.  It  is  claimed  by  most  opera- 
tors that  the  dura  should  generally  be  opened.  When  the  dura 
is  opened  and  the  operation  completed,  the  opening  in  the  dura 
should  be  closed,  if  possible,  so  as  to  secure  immediate  union. 
There  are  exceptions  to  this  rule.  Drainage  is  usually  required, 
and  a  wick  of  sterilized  gauze  is  the  best,  which  can  be  removed 
in  two  or  three  days,  or  at  the  time  of  the  first  change  of  dress- 


332  WEEKS, 

ing.  At  the  subsequent  dressings  the  strictest  antisepsis  must 
be  observed.  The  spine  is  best  supported  during  the  healing 
process  by  plaster-of-Paris  dressing,  or  by  sand-bags  placed  on 
each  side  of  the  patient.  The  usual  precautions  as  to  food  and 
drink  must  be  observed;  opiates  for  the  relief  of  pain,  care  in 
relief  of  bladder  and  bowels,  and  the  preventing  of  bed-sores. 


FRACTURES    AND    DISLOCATIONS     OF    THE    SPINE.       333 


DISCUSSION. 

Dr.  John  C.  Munro,  of  Boston. 

In  opening  the  discussion  on  this  subject,  I  shall  emphasize  the  radi- 
cal or  operative  rather  than  the  conservative  or  non-operative  treat- 
ment, because  up  to  the  present  time  the  advocates  of  the  latter  policy 
have  not  conclusively  shown  that  better  results  are  to  be  expected  than 
where  there  has  been  surgical  interference.  I  would  not  have  you  con- 
clude from  this  that  all  traumatic  cases  should  be  subjected  to  opera- 
tion ;  there  are  contraindications  not  only  in  the  local  conditions,  but 
in  the  various  general  conditions,  that  militate  against  any  operation, 
but  these  contraindications  should  be  weighed  and  judged  by  the  sur- 
geon and  not  by  the  specialist,  whether  neurological  or  medical,  and 
upon  the  surgeon  should  be  placed  the  final  responsibility  of  oper- 
ating. 

We  must  start  at  the  very  outset  in  fracture-dislocation  of  the  spine 
with  this  general  equation,  that  all  such  injuries  are  perhaps  the  most 
serious  as  regards  restoration  of  function  with  which  we  have  to  deal, 
and  that  the  outlook,  both  as  regards  function  and  life,  is  bad  under 
any  form  of  treatment.  We  must  not  lose  sight  of  this  equation  at  any 
time. 

It  is  a  common  argument  and  one  not  easily  answered — but  the 
argument  is  none  the  less  fallacious — that  recovery  after  operation 
would  have  taken  place  equally  well  without  operation.  As  a  matter 
of  fact,  there  are  very  few  surgical  conditions  that  will  not  at  times 
recover  spontaneously.  A  strong  counter-argument  is  the  not  inconsid- 
erable number  of  recorded  cases  treated  conservatively  for  weeks  or 
months  without  gain  that  have  steadily  and  surely  improved  after  oper- 
ation ;  not  always  propter  hoc,  perhaps,  but  with  every  clinical  evidence 
that  the  operation  has  proved  the  turning-point.  Take  the  worst  type 
of  injury,  for  example,  that  in  the  cervical  region.  To  say  that  the  cases 
reported  by  Winnett,  Horsley,  McCosh,  Mixter,  Hough  and  others 
would  have  done  as  well  without  operation  as  with  operation  does  not 
appeal  to  one's  surgical  instinct. 

The  risk  of  the  operation, /ifr  se,  may  be  disregarded,  provided  the 
initial  shock  of  the  accident  has  subsided.  The  number  of  my  own 
cases,  twenty-one  in  all,  may  be  too  small  from  which  to  draw  definite 
conclusions  on  some  mooted  points,  but  it  is  plenty  large  enough  to 


334  DISCUSSION. 

answer  one  question  with  regard  to  the  operation  :  the  question  of 
shock.  I  can  recall  only  one  patient  in  whom  there  was  a  temporary 
anxiety  as  to  his  condition. 

In  spite  of  all  the  brilliant  neurological  work  that  has  been  done 
within  the  last  few  years  it  is  not  yet  possible  to  absolutely  state  the 
exact  amount  or  nature  of  the  damage  done  to  the  cord.  There  are 
symptoms  like  total  loss  of  the  deep  reflexes  that  seem  to  indicate  a 
total  destruction  of  the  cord,  and  yet  an  occasional  recovery  in  such 
a  case  makes  one  hesitate  to  accept  the  hard-and-fast  rule  that  it  is 
useless  to  operate  where  this  symptom  is  present. 

I  am  glad  that  Dr.  Weeks  advocates  operation  on  the  basis  of 
exploration,  if  for  no  other  reason.  No  matter  who  the  neurologist, 
or  who  the  surgeon,  there  is  bound  to  be,  every  now  and  then,  a  case 
beyond  accurate  diagnosis,  just  as  we  so  frequently  see  in  abdominal 
lesions,  and  if  we  can  assure  the  patient  that  exploration  is  scarcely 
more  serious  in  the  one  condition  than  in  the  other,  we  have  a  firmer 
basis  for  advising  exploration  in  injuries  to  the  spine. 

I  doubt  if  opening  the  dura  materially  increases  the  risk  of  the 
operation.  I  have  never  hesitated  to  open  it,  and  recently  I  have  not 
even  troubled  to  close  it  by  suture,  and,  so  far,  there  has  been  no  ill 
effect.  Where  the  dura  is  tense  and  without  pulsation  I  look  upon  a 
free  opening  much  as  upon  an  opening  of  the  cerebral  dura.  If  the 
dura  is  not  distended,  but  there  is  reason  for  a  more  complete  exami- 
nation of  the  cord  itself,  there  need  be  no  hesitation  in  carrying  out 
this  step.  Furthermore,  we  cannot  disregard  the  possible  effect  of  a 
greatly  increased  intradural  pressure  upon  a  cord  already  injured,  but 
perhaps  not  irretrievably  so.    The  relief  of  this  pressure  may  mean  much. 

Whether  the  dura  is  open  or  not,  I  close  the  outside  wound  with 
deep  sutures,  through  and  through,  allowing  for  a  temporary  thin 
rubber  tissue  drain. 

Dr.  Weeks  has  referred  to  the  rarity  of  dislocation  without  fracture. 
One  of  my  cases,  already  reported,  showed  this  condition  at  autopsy, 
the  cord  in  the  upper  cervical  region  being  almost  completely  crushed, 
and  yet  without  any  sign  of   fracture  of  the  bony  column. 

I  still  believe  the  technique  to  be  of  importance,  but  as  I  have 
already  explained  that  in  a  published  article,  it  is  not  necessary  to 
repeat  it  here.  I  would  merely  emphasize  the  advantage  of  the  prone 
position,  with  the  chest  resting  on  pillows  and  the  head  supported 
over  the  end  of  the  table  by  the  ansesthetizer.  Packing  for  ha^mo- 
stasis ;  rapidity  and  cleanliness  are  indispensable. 


FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE.       335 

Dr.  Pontico,  of  Troy. 

That  some  of  these  cases  can  be  cured  and  gotten  into  good  shape 
without  operation,  was  proven  to  me  from  a  case  that  came  under  my 
observation  where  a  man  had  fractured  his  cervical  vertebra  by  falling 
upon  a  wagon.  He  was  completely  paralyzed  from  the  site  of  injury 
down.  I  put  him  in  bed  on  an  inclined  plane,  shaved  his  head  and 
scalp,  put  adhesive  plaster  from  the  site  of  the  accident  over  the  whole 
scalp;  put  on  a  fifteen-pound  weight  and  kept  up  perpetual  extension. 
The  man  made  a  perfect  recovery,  and  died  some  years  later  of  dis- 
ease of  the  liver.  An  autopsy  was  obtained,  and  the  fourth,  fifth  and 
sixth  vertebras  were  found  to  have  been  fractured.  They  were  all  con- 
solidated, and  the  man's  functions  were  perfect.  I  may  mention  that 
he  never  could  rotate  his  head,  but  always  had  to  turn  his  body,  prob- 
ably due  to  inflammatory  exudates. 

I  have  had  two  similar  cases,  one  occurring  in  the  same  way  as  the 
last,  and  I  am  sure  they  might  have  been  saved  in  the  same  way  if  they 
would  have  submitted  to  the  treatment. 

Dr.  S.  J.  MixTER,  of  Boston. 

I  wish  to  emphasize  the  remarks  made  in  favor  of  operation.  All 
cases  of  fracture  in  the  cervical  region  should  be  operated  upon,  if 
they  can  be  seen  in  time,  or  when  the  temperature  is  not  running  up 
to  a  fatal  termination. 

A  case  recently  reported  by  me  of  laminectomy  for  fracture  of  the 
fifth  and  sixth  vertebrae  was  very  instructive.  The  boy  broke  his  back 
by  falling,  and  there  was  absolute  loss  of  sensation,  motion  and  reflexes. 
The  case  was  about  as  unfavorable  a  one  to  look  upon  as  you  could  have. 
He  entirely  recovered  after  laminectomy,  with  the  exception  that  he 
has  v/rist-  and  toe-drop  on  one  side.  It  has  been  claimed  that  these 
cases  would  recover  without  laminectomy,  and  this  is  possibly  true. 
The  bone  in  this  case  was  driven  down  on  the  cord,  and  when  the  dura 
was  opened  no  crushing  could  be  seen,  but  considerable  bloody  fluid 
escaped.  I  think  it  is  better  not  to  sew  up  the  dura  after  it  has  been 
opened,  but  to  leave  it  open  and  to  drain  so  as  to  relieve  possible 
pressure. 

Dr.  R.  H.  Harte,  of  Philadelphia. 

I  have  listened  with  a  great  deal  of  interest  to  Dr.  Weeks'  very 
instructive  paper,  and  I  strongly  indorse  the  remarks  which  he  made 


336       FRACTURES    AND     DISLOCATIONS    OF    THE    SPINE. 

in  favor  of  early  operation,  as  I  feel  convinced  that  much  benefit  can 
be  done  to  cases  which  otherwise  would  be  absolutely  hopeless  if 
prompt  operation  were  neglected.  A  case  is  now  in  my  ward  in  which 
a  gunshot  wound  was  received,  severing  the  cord  in  about  the  mid-dorsal 
region.  In  this  case  there  was  a  loss  of  substance  of  over  half  an  inch. 
The  contused  ends  of  the  cord  were  freed  and  the  clean  surfaces 
approximated  with  catgut  sutures.  This  may  seem  almost  paradoxi- 
cal, but  now  it  is  very  evident  that  regeneration  of  the  cord  is  slowly 
taking  place,  as  sensation  and  motion  are  markedly  present.  I  feel  con- 
vinced that  our  knowledge  of  cord  regeneration  is  in  its  infancy,  and 
that  much  can  yet  be  learned  in  regard  to  the  surgery  of  the  spinal 
cord  future. 

Dr.  Weeks.  I  might  mention  that  the  man  on  whom  I  operated 
was  aged  eighty  years.  I  believe  the  majority  of  surgeons  advise  open- 
ing the  dura,  but  there  are  exceptions  to  this  rule.  Exception  obtained 
in  my  case,  inasmuch  as  the  operation  was  done  at  the  patient's  home, 
where  I  did  not  feel  sure  of  my  asepsis.  Under  those  circumstances 
the  opening  of  the  dura  had  better  be  omitted,  unless  there  are  dis- 
tinct indications  for  opening  it.  Personally,  I  should  hesitate  about 
opening  it  under  such  circumstances. 


RADICAL  CURE  OF  INGUINAL  AND  FEMORAL 
HERNIA,  WITH    A   REPORT   OF   EIGHT 
HUNDRED  AND    FORTY- 
FIVE  CASES. 


By  WILLIAM  B.  COLEY,  M.D., 

NEW   YORK   CITY. 


The  decade  that  has  just  passed  may  be  said  to  have  practically 
settled  the  question  as  to  the  possibility  of  curing  inguinal  and 
femoral  hernia  by  operative  methods  of  treatment.  Prior  to 
this  time,  although  numerous  methods  had  been  enthusiastically 
advocated,  and  had  been  tried,  even  with  all  the  advantages  of 
antiseptic  technique,  the  results  were  such  as  to  go  far  toward 
justifying  the  opinion  of  the  most  conservative  and  judicial 
surgeons,  that  these  operations  were  not  entitled  to  the  term 
"radical  cure,"  and  were  often  of  very  doubtful  efficacy.  To- 
day the  whole  attitude  of  surgeons  toward  the  operative  relief 
of  hernia  has  entirely  changed,  and  the  general  practitioners 
as  well  are  waking  up  to  the  fact  that  the  time  has  now  come 
when,  instead  of  selecting  special  cases  of  hernia  for  operation, 
they  had  better  select  special  cases  for  truss  treatment,  and 
otherwise  prescribe  the  remedy  to  seek  operative  relief.  This 
change  has  been  due  to  two  factors :  first,  the  steady  decrease 
in  the  mortality  attending  operation,  and  second,  the  vastly 
improved  results  that  have  followed  improved  methods  and 
improved  technique. 

Whereas  ten  years  ago  the  mortality  of  operation  for  non- 
strangulated  hernia  in  four  of  the  largest  London  hospitals  was 
6  per  hundred,  to-day,  in  competent  hands,  the  mortality  is  less 
than  yi  per  hundred,  or  practically  nil  in  uncomplicated  cases. 
The  early  mortality  was  sufficient  to  deter  conservative  sur- 

Am  Surg  2a 


338  COLEY, 

geons  from  advising  operation  in  persons  but  little  inconveni- 
enced by  wearing  a  truss,  and  when,  in  addition  to  this,  there 
was  the  fact  that  40  to  50  per  cent,  of  the  cases  relapsed  within 
two  or  three  years  after  operation,  it  was  no  wonder  that  many 
patients  who  understood  the  situation  were  unwilling  to  try 
operative  treatment. 

In  no  department  of  abdominal  surgery  the  world  over  has 
there  been  more  earnest  and  untiring  work  done  than  in  the 
operative  treatment  of  hernia,  and,  although  I  believe  that  the 
method  introduced  by  Bassini  in  1890  marks  the  highest  point 
in  the  evolution  of  an  ideal  operation  for  hernia,  much  honor 
and  credit  are  due  to  other  men  who  have  devised  methods  but 
little  short  of  his  in  value. 

I  shall  first  consider  the  radical  cure  of  inguinal  hernia  in  the 
male.  What  are  the  indications  for  operation  ?  A  decade  ago 
operative  treatment  was  restricted  to  very  large  hernise  or  to 
irreducible  hernia,  or  hernia  difficult  or  impossible  of  control 
by  mechanical  means.  To-day  the  indications  are  much  wider 
in  scope.  I  would  advise  operation  in  all  adults  under  fifty 
years  of  age  in  good  health,  except  in  cases  of  very  large,  irre- 
ducible scrotal  hernia.  I  would  also  except  very  large  reducible 
hernia  of  long  standing,  in  which  the  reduction  of  the  contents 
into  the  abdomen  materially  increases  the  tension  of  the  abdom- 
inal walls  and  interferes  with  respiration.  Operation  in  these 
cases  is  not  free  from  risk,  and  the  chances  of  obtaining  a  per- 
manent cure  are  slight.  On  the  other  hand,  there  are  many 
patients,  even  up  to  the  age  of  seventy,  with  hernife  which, 
though  not  of  great  size,  are  very  difficult  to  control  with  a  truss, 
and  the  danger  of  strangulation  is  ever  present.  Such  patients, 
if  in  good  health  and  not  too  obese,  are  proper  subjects  for 
operative  treatment. 

The  indication  for  operative  intervention  in  children  requires 
separate  consideration.  When  I  published,  in  1893,  my  first 
paper  upon  the  radical  cure  of  hernia  in  children,  with  a 
report  of  5  i  cases,  the  criticism  was  made  by  some  surgeons 
that  hernia  in  children  should  not  be  operated  upon,  inas- 
much as  it  could  always  be  cured  by  mechanical  means.     As 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL   HERNIA.     339 

a  reply  to  this  criticism  I  made  an  analysis  of  upward  of  15,000 
cases  of  hernia  in  adults  observed  at  the  Hospital  for  Ruptured 
and  Crippled,  in  New  York,  with  a  view  of  ascertaining,  as  nearly 
as  possible,  how  many  gave  a  history  of  hernia  in  infancy  and 
childhood.  A  careful  study  of  these  cases  warranted  the  con- 
clusion that  at  least  one-third  of  all  infants  and  children  under 
fourteen  years  with  inguinal  hernia  are  not  cured  by  mechani- 
cal treatment,  and  hence  the  employment  of  operative  methods 
in  hernia  occurring  in  children  is  entirely  justified,  provided 
those  methods  are  free  from  risk.  The  only  death  I  have  had 
in  upward  of  500  hernia  operations  in  children  was  due  to 
double  pneumonia  following  ether.  Therefore,  it  may  safely  be 
stated  that  the  risk  is  not  appreciable. 

Since  the  publication  of  the  paper  referred  to  there  has  been 
a  constant  tendency  to  extend  more  and  more  radical  cure 
methods  to  children,  until  at  present  we  are  regarded  at  the 
Hospital  for  Ruptured  and  Crippled  as  ultra-conservative.  In- 
stead of  operating  upon  the  majority  of  children  and  infants,  as 
is  recommended  by  many  of  the  French  surgeons,  and  is  the 
practice  of  not  a  (qw  American  surgeons,  our  plan  is  to  operate 
very  rarely  under  the  age  of  four  years.  Most  patients  with 
inguinal  hernia  under  the  age  of  four  years  may  be  cured  with 
a  truss,  and  it  is  well  to  give  them  the  trial.  After  the  age  of 
four  years  and  up  to  fourteen  years  we  advise  truss  treatment 
for  one  or  two  years,  at  the  end  of  which  time,  if  the  hernia 
still  comes  down  and  the  ring  is  large,  we  believe  there  is  little 
to  be  gained  by  waiting,  and  advise  operation.  Among  dispen- 
sary patients  it  is  often  difficult  to  provide  the  proper  care  at 
home  in  the  management  of  the  truss  necessary  to  success,  and 
in  such  cases  the  question  of  operating  earlier  may  be  left  to  the 
judgment  of  the  surgeon. 

Adherent  omentum,  though  comparatively  rare  in  children, 
is  occasionally  met  with,  and  when  present  operation  should  be 
performed  without  delay. 

Reducible  hydrocele  or  fluid  in  the  hernial  sac  is  more  fre- 
quently seen,  and  this  condition  precludes  the  hope  of  cure  by 
truss  treatment,  and  calls  for  operation. 


340  CO  LEY, 

Methods  Employed.  I  have  already  in  former  papers  dis- 
cussed the  relative  value  of  the  various  methods  of  operation  for 
radical  cure,  and  at  present  shall  do  little  more  than  describe  the 
methods  personally  employed  in  the  cases  reported.  Time  is 
wasted  in  a  theoretical  discussion  of  the  relative  value  of  the  dif- 
ferent methods  of  operation  for  the  radical  cure  of  hernia.  The 
value  of  a  method  can  neither  be  determined  by  the  reputation  of 
the  surgeon  who  has  originated  it,  nor  by  the  distinction  of  the 
men  who  accept  it.  It  can  be  settled  only  by  a  scientific  analysis 
of  results  subjected  to  the  test  of  time.  By  time  I  do  not  mean 
the  number  of  years  since  the  operation  was  performed,  but  the 
careful  tracing  of  patients  to  final  results  or  for  long  periods  of 
time. 

The  chief  object  of  this  paper  is  to  furnish,  by  the  presenta- 
tion of  a  considerable  number  of  cases  operated  upon  by  a  single 
method  and  uniform  technique,  additional  data  that  may  be  of 
help  in  solving  the  question  of  choice  of  methods  in  the  radical 
cure  of  hernia. 

The  method  of  Bassini,  when  first  published,  appealed  to  me 
strongly  as  superior  mechanically  to  any  hitherto  described,  and 
his  practical  results  seemed  to  bear  out  the  theoretical  supe- 
riority. 

The  chief  advantage,  to  my  mind,  is  the  fact  that  the  only 
weak  place  in  the  wound,  viz.,  where  the  cord  emerges  through 
the  internal  ring,  is  protected  by  the  overlying  layer  of  the 
external  oblique  aponeurosis,  so  that  a  recurrence  can  only  take 
place  by  the  hernial  protrusion  forcing  itself  directly  through 
the  aponeurosis  at  this  point  or  taking  a  right-angled  course 
downward  beneath  the  external  oblique.  With  perfect  wound- 
healing  this  ought  never  to  occur,  and  we  find  in  actual  prac- 
tice it  very  seldom  does.  However,  to  correct,  as  far  as  possible, 
this  one  weak  point  of  the  operation,  I  have  slightly  modified 
Bassini's  technique  by  introducing  a  single  suture  above  the 
cord,  bringing  the  internal  oblique  muscle  into  apposition  with 
Poupart's  ligament  above  the  cord,  thus  making  the  cord  come 
out  between  the  two  upper  sutures.  The  only  other  change  that 
I  have  adopted  has  been  the  substitution  of  an  absorbable  suture — 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL   HERNIA.     34 1 

chromicized  kangaroo  tendon — for  the  silk  sutures  originally- 
employed  by  Bassini,  and  which  he  still  uses.  The  advan- 
tages of  absorbable  sutures  I  will  discuss  later.  In  introducing 
the  deep  layer  of  buried  sutures  the  first  stitch  is  placed  so  that 
it  just  touches  the  lower  edge  of  the  cord  when  the  latter  is  held 
vertically  to  the  plane  of  the  abdomen.  This  furnishes  a  uni- 
form guide  as  to  how  high  up  the  canal  the  sutures  should  go. 
The  sutures  are  introduced  from  within  outward  by  a  full  curved 
Hagedorn  needle  without  a  holder,  and  the  index  finger  of  the 
left  hand  passed  just  beneath  the  muscles  guards  the  peritoneum 
from  harm.  Four  to  five  sutures  suffice  below  the  cord,  and  one 
above.  The  aponeurosis  is  closed  also  from  above  downward, 
but  with  a  continuous  suture  of  kangaroo  tendon  of  fine  calibre. 
The  skin  is  closed  with  No.  i  catgut,  without  drainage.  A 
dressing.of  10  per  cent,  iodoform  and  moist  i  :  5000  bichloride 
gauze  is  then  applied,  and  the  wound  not  dressed  until  the 
seventh  day.  In  children  a  plaster-of-Paris  spica  is  applied  in 
addition  to  the  usual  dressing. 

The  technique  has  been  given  somewhat  in  detail  for  the 
reason  that  it  has  been  uniformly  employed  during  the  entire 
ten  years,  and  may  have  some  bearing  upon  the  wound  healing. 

Wound  Healing.  Prior  to  the  introduction  of  rubber  gloves, 
two  and  one-half  years  ago,  96  per  cent,  of  the  cases  healed  by 
primary  union.  After  the  gloves  were  used  for  assistants  and 
cots  or  gloves  by  myself  I  had  a  series  of  200  cases  with  but 
one  suppuration,  and  this  was  due  to  a  streptococcus  infection 
from  the  skin  of  the  patient,  as  shown  by  scrapings  taken  from 
the  skin  at  the  time  of  operation.  I  believe  that  these  results 
in  wound  healing  are  in  no  small  part  due  to  the  fact  that  all 
bruising  of  tissue  has  been  carefully  everted  and  operations 
have  been  rapidly  performed.  In  uncomplicated  cases  the 
average  time  has  been  twelve  to  twenty  minutes.  All  bleed- 
ing-points have  been  carefully  tied,  and  the  aim  has  been  to 
make  the  field  of  operation  as  clearly  defined  and  as  dry  as  a 
dissection  upon  the  cadaver. 

The  buried  sutures  employed — kangaroo  tendon  and  catgut 
— have  been  prepared  by  Van  Horn  &  Co.,  of  New  York,  and 


342  COLEY, 

during  the  earlier  period  were  sterilized  by  boiling  in  absolute 
alcohol  under  pressure ;  during  recent  years  by  the  cumol 
method.  These  sutures  have  been  subjected  to  frequent  bac- 
teriological tests,  and  have  always  proved  sterile. 

Advantages  of  Absorbable  Sutures.  The  objections  that 
have  been  offered  from  time  to  time  to  the  use  of  absorbable 
buried  sutures  rests  entirely  upon  the  assumption  that  it  is  im- 
possible to  render  such  sutures  perfectly  sterile.  That  this 
assumption  is  without  foundation  in  fact  is  conclusively  proven 
not  only  by  my  own  experience,  but  also  that  of  Drs.  Bull,  De 
Garmo,  and  others  who  have  used  these  sutures  for  many  years. 
It  is  still  further  proved  by  the  frequent  bacteriological  tests, 
which  invariably  have  shown  these  sutures  to  be  sterile.  The 
ideal  buried  suture  in  operations  for  the  radical  cure  of  hernia 
is  one  that,  while  remaining  unabsorbed  sufficiently 'long  to 
secure  thorough  union  of  the  parts  in  apposition,  becomes  ab- 
sorbed before  it  has  had  time  to  cause  irritation  and  subsequent 
sinus  formation.  Both  catgut  and  kangaroo  tendon  may  be  so 
treated  with  chromic  acid  as  to  remain  in  the  tissues  any  de- 
sired length  of  time  before  absorption.  For  hernia  operations 
I  believe  that  this  period  should  not  be  more  than  three  to  four 
weeks. 

The  disadvantages  attending  the  use  of  non-absorbable  buried 
sutures  for  hernia  operations  have  already  been  so  frequently 
pointed  out  by  Dr.  Bull  and  myself  that  I  will  not  do  more 
than  briefly  repeat  these  important  points. 

1.  Late  sinus  formation  may  and  frequently  does  occur  with 
perfect  primary  union  at  the  time  of  operation. 

2.  The  usefulness  of  a  buried  suture  has  been  fulfilled  at  the 
end  of  three  to  four  weeks,  after  which  time,  if  non-absorbable, 
it  will  cut  through  the  tissues  until  there  is  no  further  tension, 
and  henceforth  remain  as  a  foreign  body,  capable  of  causing 
much  annoyance  and  predisposing  to  relapse  by  sinus  forma- 
tion and  long-continued  suppuration. 

3.  If  the  object  at  which  we  aim  is  the  cure  of  the  patient 
we  can  best  obtain  this  object  by  the  use  of  absorbable  sutures. 
I  have  personally  observed  these  cases  in  which  non-absorbable 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL  HERNIA.     343 

sutures  were  used,  with  sinus  formation  more  than  three  years 
after  operation,  although  the  original  wound  had  healed  by- 
perfect  primary  union. 

I  have  observed  more  than  thirty  cases  of  sinus  formation 
following  hernia  operations  in  which  silk,  silkworm-gut,  and 
silver-wire  had  been  used  for  the  buried  suture.  The  last  case 
was  a  patient  operated  upon  in  January,  1900 ;  a  sinus  followed 
operation,  necessitating  his  remaining  in  the  hospital  until  the 
following  May.  In  April  a  portion  of  the  wire  was  removed, 
but  the  wound  did  not  heal.  He  left  the  hospital  in  May  and 
made  frequent  visits  to  an  out-patient  department  to  have  the 
sinus  dressed.  It  continued  to  discharge  freely  until  finally,  in 
December,  nearly  a  year  from  the  time  of  operation,  the  re- 
mainder of  the  wire  was  removed  and  the  sinus  finally  closed. 
In  the  meantime  the  rupture  had  recurred  and  become  several 
times  its  original  size.  So  much  suppuration  had  occurred  and 
formation  of  scar  tissue  that  further  operation  is  impossible, 
and  as  the  rupture  cannot  be  controlled  by  a  truss,  the  patient 
is  practically  an  invalid.  The  great  majority  of  the  cases  with 
slowly  healing  sinuses  have  been  followed  by  relapse. 

This  list  of  unfortunate  results  following  the  use  of  non- 
absorbable sutures  would  seem  sufficiently  large  to  demon- 
strate the  disadvantages  of  such  sutures. 

The  value  of  Bassini's  operation  cannot  be  judged  by  the 
number  of  relapses  that  have  occurred  in  the  hands  of  a  few 
surgeons,  however  distinguished,  who  have  operated  on  but  a 
comparatively  small  number  of  patients.  In  many  of  the  so- 
called  Bassini  operations  the  ideal  operation  could  not  have 
been  performed,  as  proved  by  the  short  cicatrix  of  the  wound. 
Perfect  familiarity  with  the  technique  of  the  operation  cannot 
be  acquired  in  operating  a  few  times.  My  experience  with 
recurrent  hernia  at  the  Hospital  for  Ruptured  and  Crippled 
shows  that  a  large  proportion  of  the  patients  with  relapses 
from  Bassini's  operations  were  operated  upon  by  surgeons 
whose  experience  was  comparatively  limited.  It  is  an  un- 
doubted fact,  as  our  records  show,  that  while  operations  for  the 
radical  cure  of  hernia  have  been  steadily  and  rapidly  on  the 


344  COLEY, 

increase  for  the  past  ten  years,  the  number  of  patients  with  a 
recurrence  that  present  themselves  at  the  hospital  for  trusses 
has  been  just  as  steadily  on  the  decrease.  During  the  year 
1 89 1  sixty-four  patients  with  recurrent  hernia  applied  for  treat- 
ment at  the  Hospital  for  Ruptured  and  Crippled,  while  during 
the  past  year  (1900)  but  twenty-six  applied.  This  shows  more 
conclusively  than  anything  else  the  vast  improvement  in  present 
methods  and  technique  over  those  in  vogue  a  decade  ago ;  that 
this  fact  is  still  further  confirmed  by  the  paper  of  Delbet  on 
"The  Remote  Results  of  the  Radical  Cure  of  Hernia."^  Dur- 
ing the  first  six  months  of  the  year  1900  he  states  that  in  the 
"Service  des  Bandages"  in  Paris  only  seven  patients  with  a 
recurrent  hernia  represented  themselves.  The  author  concludes 
that  "  if  the  enormous  number  of  operations  performed  for  the 
radical  cure  of  hernia  at  the  Paris  Hospital  is  taken  into  con- 
sideration, the  small  number  of  recurrent  herniae  observed  in 
institutions  for  the  supply  of  trusses  is  a  sure  indication  that 
operations  for  the  cure  of  this  affliction  are  really  radical." 

Cases  of  Unusual  Interest.  Hernia  of  the  CoBciim  and 
Sigmoid  Flexure.  I  have  operated  upon  upward  of  thirty  cases 
of  hernia  of  the  sigmoid  or  csecum  and  appendix.  A  consid- 
erable number  of  these  have  been  cases  of  sliding  hernia,  or 
hernie  par  glissement,  as  designated  by  the  French  authors.  In 
these  the  usual  peritoneal  sac  is  imperfect,  generally  lacking  in 
its  posterior  aspect.  This  condition,  while  much  more  common 
in  the  csecum,  I  have  occasionally  observed  in  hernia  of  the 
sigmoid  flexure.  The  difficulty  of  operating  upon  this  class  of 
slipped  or  sliding  hernia  of  the  caecum  and  sigmoid  has  been 
recently  pointed  out  by  Dr.  Weir.  Clinically  this  condition  can 
be  frequently  diagnosticated  by  the  fact  that  attempts  to  replace 
the  protruding  bowel  into  the  abdominal  cavity  accomplish 
little.  While  a  certain  portion  may  be  reduced,  a  considerable 
portion  is  always  left  behind,  and  this  can  usually  be  differ- 
entiated from  adherent  omentum. 

In  a  number  of  cases   which  I  have  observed  at  the  Hospital 

'   Bulletins  et  Mdmoires  de  la  Societc  de  Cliir.,  1900,  No.  28. 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL   HERNIA.     345 

for  Ruptured  and  Crippled  the  diagnosis  was  made  before  oper- 
ation on  basis  of  this  finding. 

According  to  Dr.  Weir,  the  sliding  hernise  are  more  frequent 
in  the  left  side  of  males,  and  in  middle  and  advanced  life.  The 
usual  history  prior  to  operation  is  that  of  a  hernia,  at  first  redu- 
cible, but  not  always  easy  to  control  with  a  truss.  This  con- 
dition soon  passes  into  one  of  permanent  irreducibility. 

My  own  experience  does  not  confirm  the  opinion  of  Dr.  Weir, 
that  the  sliding  herniae  are  more  common  on  the  left  than  on 
the  right  side,  nor  do  I  believe  that  they  are  more  common  in 
males  in  middle  or  advanced  life — in  fact,  very  few  statistics 
upon  operations  for  hernia  in  children,  with  sufficiently  full 
details  for  comparison,  are  available.  An  analysis  of  775  cases 
of  hernia  in  children  operated  upon  at  the  Hospital  for  Rup- 
tured and  Crippled  shows  a  comparatively  large  number  of 
caical  hernitTe,  a  considerable  proportion  of  which  are  of  the 
variety  described  by  Dr.  Weir. 

My  own  personal  statistics  show  a  greater  proportion  of  slid- 
ing hernia  in  children  than  in  adults ;  and  I  believe  that  when 
statistics  are  sufficiently  complete  to  make  a  fair  comparison 
possible  we  shall  find  this  to  be  true  in  general. 

The  operative  treatment  of  this  form  of  hernia  is  by  no  means 
easy.  Weir  states  that  in  his  earlier  cases  he  attempted  to  push 
up  the  bowel  toward  the  internal  ring,  and  to  hold  it  there  by 
sutures  carried  from  below  the  intestine  to  the  side  of  the  ring 
or  through  the  abdominal  wall.  This  operation  proved  a  failure. 
In  2  more  recent  cases  he  separated  the  bowel  from  its  poste- 
rior attachments  and  then  made  a  flap  of  the  peritoneal  portion 
of  the  sac,  which  was  turned  backward  and  sutured  behind  the 
gut  as  far  as  practicable.  These  2  cases  were  well  eight  months 
after  operation. 

In  my  own  cases  I  have  followed  the  plan  of  separating  the 
caecum  and  bowel  sufficiently  high  up  to  permit  of  complete 
reduction.  The  peritoneal  opening  is  then  sutured  with  cat- 
gut, and  the  abdominal  wound  is  closed  in  three  layers,  as  in 
Bassini's  operation,  without  transplantation  of  the  cord.  In  2 
cases  only  has  relapse  occurred. 


346  CO  LEY, 

Ingiimal  Hernia  Associated  %vith  Undescended  Testes.  I  have 
operated  upon  30  cases  of  undescended  or  partially  descended 
testes  associated  with  hernia.  Fourteen  of  these  cases  were 
between  ten  and  fourteen  years.  The  testis  was  not  removed 
in  a  single  case,  and  I  believe  that  in  practically  all  cases  of 
undescended  testis  associated  with  hernia  in  which  operation  is 
indicated  it  will  be  found  possible  to  bring  the  testis  outside  of 
the  external  ring.  The  canal  can  then  be  closed  by  Bassini's 
method,  or  by  allowing  the  cord  to  come  out  of  the  lower  angle 
of  the  wound,  without  transplantation.  This  latter  method  per- 
mits the  testis  to  be  brought  down  one-half  to  three-quarters  of 
an  inch  lower  than  when  the  cord  is  transplanted. 

In  most  of  these  cases  the  testis  was  considerably  smaller 
than  that  on  the  opposite  side.  In  some  of  my  earlier  cases, 
operated  upon  between  1891  and  1895,  I  attempted  to  keep  the 
testis  down  by  anchoring  it  in  the  scrotum,  either  to  the  scrotum 
or  to  a  wire  frame  outside  of  the  scrotum.  In  most  of  these 
cases  the  testis  retracted  to  a  position  just  outside  the  external 
ring,  and,  as  there  seemed  to  be  very  little  gained  by  the  various 
methods  of  anchoring,  I  soon  gave  them  up.  With  one  excep- 
tion all  my  cases  were  operated  by  Bassini's  method.  The 
results,  as  far  as  the  cure  of  the  hernia  is  concerned,  have  been 
perfect  in  every  instance.  I  believe  that  operation  is  rarely 
indicated  as  a  routine  measure  before  the  age  of  ten  and  twelve 
years,  for  the  reason  that  in  many  cases  the  testis  descends  into 
the  scrotum  or  below  the  external  ring  about  the  age  of 
puberty.  The  accompanying  rupture  is  usually  small,  has  little 
tendency  to  become  strangulated,  and  maybe  easily  retained  by 
a  light  spring  truss,  the  pad  of  which  rests  above  the  testis. 

Ingidno-perineal  Hernia  Associated  with  Maldescent  of  the 
Testis.  I  have  observed  6  cases  of  testis  in  the  perineum,  and 
in  4  of  these  there  was  an  accompanying  well-developed  hernia, 
the  latter  following  the  course  of  the  testis,  and  appearing  in 
the  perineum  rather  than  the  scrotum.  In  one  of  these  cases, 
already  reported,  in  which  the  hernia  was  the  size  of  a  cocoa- 
nut  and  the  testis  very  small  and  ill-developed,  the  testis, 
together    with  the  entire  pouch,   was  removed    and  the  canal 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL    HERNIA.     347 

closed  in  three  layers.  The  patient  remained  well  for  about 
three  years,  and  death  resulted  from  drowning.  In  the  other  3 
cases  the  testis  was  apparently  full  developed,  and  I  was  able  to 
preserve  a  sufficient  amount  of  peritoneum  to  make  a  perfect 
tunica  vaginalis.  I  then  formed  a  new  pouch  with  the  finger  in 
the  hitherto  empty  scrotum,  into  which  the  testis  and  its  new 
tunica  were  transplanted. 

The  patients  all  made  an  excellent  recovery  and  have  remained 
free  from  recurrence  up  to  the  present  time,  one  to  three  years 
after  operation. 

Properito7ieal,  or  Interstitial  Hernia. — Four  cases  were  inter- 
stitial or  properitoneal  hernia.  Interstitial  hernia  is  generally 
associated  with  undescended  testis.  Of  42  cases  of  interstitial 
hernia  collected  by  Langdon,  there  were  only  two  instances 
in  which  the  testes  were  normally  developed  in  the  scrotum. 
The  position  of  the  testis  varied  between  wide  limits.  In  2  cases 
it  was  high  up  in  the  scrotum ;  in  two  others,  just  outside  the 
external  ring  ;  in  26  it  was  situated  in  the  canal.  The  relative 
frequency  of  interstitial  hernia,  as  estimated  by  Langdon,  is  i  in 
IIOO  cases.  Of  my  own  cases,  the  one  most  worthy  of  note 
was  a  properitoneal  Richter  hernia,  occurring  in  a  boy,  aged  fif- 
teen years.  Operation  was  performed  about  fifteen  hours  after 
strangulation.  A  loop  of  small  intestine  was  found  tightly 
constricted  by  the  neck  of  the  sac  at  the  internal  ring,  includ- 
ing about  seven-eighths  of  the  lumen  of  the  bowel.  The  patient 
made  an  excellent  recovery. 

Radical  Cjtre  of  Inguinal  Hernia  in  the  Female.  Up  to  the 
present  time  I  have  operated  upon  155  cases  of  inguinal 
hernia  in  the  female  without  a  single  relapse.  The  method 
employed  I  have  recently  described  in  detail,^  and  will 
merely  say  that  the  technique  is  practically  the  same  as  in 
the  operation  for  inguinal  hernia  in  the  male,  with  the  excep- 
tion that  the  round  ligament,  after  having  been  carefully  dis- 
sected from  the  sac,  is  allowed  to  drop  back  into  the  lower 
angle  of  the   wound.     The  canal  is  closed  in  two  layers,  pre- 

*  Annals  of  Surgery,  December,  1900. 


348  COLEY, 

cisely  the  same  as  in  the  male.  The  round  ligament  as  it 
approaches  the  pubic  bone  occupies  so  little  space  that  it 
requires  a  much  smaller  opening  than  the  cord  in  the  male ; 
and  my  own  results  would  seem  to  show  that  there  is  no 
necessity  for  transplanting  it,  as  has  been  advocated  by  Kelly 
and  others.  The  dissection  of  the  sac  from  the  round  liga- 
ment, while  somewhat  more  difficult  than  dissection  of  the 
sac  from  the  cord  in  the  male,  can,  I  believe,  always  be  accom- 
plished with  comparative  ease.  And  therefore  I  do  not  think 
that  the  excision  of  the  round  ligament  with  the  sac,  as  advo- 
cated by  Championniere,  is  ever  called  for.  The  neck  of  the 
sac  can  always  be  easily  reached,  and  the  ligature  or  suture 
placed  well  beyond  the  sac,  where  it  widens  out  into  the 
general  peritoneal  cavity,  both  in  the  male  and  the  female, 
without  cutting  the  internal  oblique  muscle.  The  cutting 
of  the  internal  oblique  greatly  weakens  the  canal,  I  am  con- 
vinced, and  increases  the  chances  of  relapse.  Up  to  the 
present  time  but  few  statistics  are  available  bearing  upon 
the  relative  results  of  the  various  methods  for  the  cure 
of  inguinal  hernia  in  the  female.  Among  the  459  cases 
of  hernia  operated  upon  at  the  Johns  Hopkins  Hospital,  and 
reported  by  Bloodgood,  only  39  were  of  this  variety.  The 
round  ligament  was  excised  in  20  cases,  and  the  internal  oblique 
muscle  divided  and  transplanted.  In  6  cases  the  ligament 
was  excised,  but  the  internal  oblique  not  divided.  In  3  the 
round  ligament  was  not  disturbed,  but  the  internal  oblique  was 
divided  and  transplanted.  In  5  cases  the  round  ligament  was 
left  undisturbed  and  the  internal  oblique  not  divided.  Perfect 
results  were  noted  in  21  cases,  in  6  of  which  the  patient  had 
remained  well  from  three  to  eight  years.  In  one  case  there 
was  a  recurrence. 

Championniere  has  recently  reported  70  cases  with  3  relapses. 

The  ages  of  my  personal  cases  ranged  between  four  and 
seventy  years.  The  average  time  they  were  confined  to  bed 
was  ten  days.  Most  of  them  were  allowed  to  go  home  at 
the  end  of  two  weeks.  Thirteen  of  the  patients  have  been 
traced. 


RADICAL  CURE   OF    INGUINAL  AND   FEMORAL    HERNIA.     349 

Femoral  Hernia.  Although  a  large  number  of  methods  for 
the  radical  cure  of  femoral  hernia  have  been  proposed  from 
time  to  time,  it  has  been  impossible  to  judge  of  their  relative 
value  except  on  theoretical  grounds,  for  the  reason  that,  with 
the  single  exception  of  Bassini's  statistics  for  femoral  hernia, 
very  few  cases  have  been  reported  or  traced  for  any  length  of 
time.  Bassini  published  a  series  of  53  cases  operated  upon  by 
his  own  method,  with  no  mortality  and  without  a  single  relapse 
in  41  cases  traced  from  one  to  nine  years. 

Although  Bacon,  in  his  recent  paper/  attempts  to  show 
that  Bassini's  method  is  mechanically  defective,  these  practical 
results  go  far  toward  outweighing  any  theoretical  shortcomings. 
Personally,  I  have  operated  upon  54  cases  of  femoral  hernia 
during  the  past  nine  years,  and  thus  far  but  one  relapse  has 
been  observed.  Sixteen  of  these  cases  were  operated  upon  by 
Bassini's  method,  all  the  others  by  the  so-called  purse-string 
method  originally  proposed,  I  believe,  by  Gushing,  of  Boston. 
The  technique  in  brief  is,  first,  to  thoroughly  free  the  sac  well 
beyond  the  neck  ;  high  ligation  of  the  sac  and  closure  of  the 
canal  by  means  of  a  purse-string  suture  of  chromicized  kangaroo 
tendon.  The  suture  is  introduced  through  Poupart's  ligament 
or  the  inner  portion  of  the  roof  of  the  canal,  or  crural  arch, 
from  where  it  passes  downward  into  the  pectineal  muscle  or 
floor  of  the  canal,  outward  through  the  fascia  lata  overlying  the 
femoral  vein,  and  upward  through  Poupart's  ligament  or  roof 
of  the  canal,  emerging  about  three-fourths  of  an  inch  from  the 
point  of  introduction.  On  tying  the  suture,  the  floor  of  the 
canal  is  brought  into  apposition  with  the  roof,  and  the  femoral 
opening  is  completely  obliterated.  The  superficial  fascia  may 
then  be  closed  with  catgut  or  fine  tendon,  and  the  skin  either 
with  catgut  or  silk.  This  method  of  closing  the  femoral  canal 
is  considerably  simpler  than  Bassini's,  and  from  the  results  that 
I  have  obtained  I  am  inclined  to  give  it  the  preference,  except 
possibly  in  hernia  with  a  very  large  opening.  In  38  cases 
operated  upon  by  this  method  not  a  single  relapse  has  been 

'  Yale  Medical  Journal,  January,  1901. 


350  COLEY, 

observed.  The  only  recurrence  that  took  place  in  the  54 
cases  occurred  in  a  case  operated  upon  by  Bassini's  method,  a 
woman,  aged  thirty-five  years,  with  femoral  hernia  the  size  of 
an  egg.  Operation  was  performed  in  March,  1896.  Curiously 
enough,  this  is  the  only  case  of  femoral  hernia  in  which  sup- 
puration occurred,  which  delayed  the  wound  healing  four 
weeks.  A  very  slight  relapse  took  place  a  year  and  a  half 
later.  I  personally  examined  the  patient  two  weeks  ago,  five 
years  after  operation,  and,  although  she  does  not  wear  a  truss, 
scarcely  more  than  an  exaggerated  impulse  could  be  detected. 

In  all  operations  for  femoral  hernia  I  believe  it  to  be  most 
important  to  thoroughly  free  the  canal  from  all  extraperitoneal 
fat.  As  regards  the  period  of  convalescence,  I  have  kept 
patients  in  the  hospital  for  a  little  shorter  time  than  in  inguinal 
hernia,  allowing  them  to  sit  up  on  the  tenth  day  and  to  go 
home  at  the  end  of  the  twelfth  or  fourteenth  day.  No  truss  has 
been  worn  after  operation  in  any  case. 

A  Study  of  Relapsed  Cases.  An  analysis  of  the  relapsed 
cases  in  my  series  is  of  interest,  inasmuch  as  in  nearly  every 
instance  a  sufficient  cause  for  the  relapse  can  be  found.  Of 
776  cases  of  inguinal  hernia  operated  upon  by  Bassini's  method, 
with  kangaroo  tendon  for  the  buried  sutures,  six  relapses  have 
been  observed.     These  occurred  in  the  following  cases. 

Case  I. — Male,  aged  thirty-five  years,  with  large  inguino-perineal 
hernia.  Operation  was  performed  on  July  9,  1896.  The  testis  was 
preserved,  but  was  not  transplanted  into  the  scrotum,  as  in  my  two 
later  cases  of  hernia  of  this  variety.  The  wound  was  closed  by  Bas- 
sini's method  and  healed  by  primary  union.  The  patient  was  very 
stout,  and  had  much  adipose  tissue.  In  addition  he  was  a  butcher, 
and  resumed  work  immediately  after  leaving  the  hospital  and  did 
heavy  lifting.  The  hernia  recurred  four  months  later,  being  the  size 
of  a  pigeon's  egg. 

Case  II. — Male,  aged  twenty-seven  years,  with  large,  irreducible 
omental  scrotal  hernia  of  eight  years'  duration.  Operation  was  per- 
formed July  I,  1897,  Bassini's  method  being  employed.  The  wound 
healed  by  primary  union.  Twenty  months  after  operation  there  was 
a  slight  weakness  in  the  canal,  and  a  truss  was  advised,  though  the 


RADICAL  CURE   OF    INGUINAL  AND   FEMORAL    HERNIA.     35I 

rupture  had  never  come  down,  and  one  might  well  hesitate  to  call  it 
a  relapse. 

Case  III. — Male,  aged  twenty-five  years,  with  large  scrotal,  right 
inguinal  hernia,  was  operated  upon  in  fall  of  1894  by  Bassini's  method. 
He  remained  perfectly  well,  doing  heavy  lifting  without  support,  and 
was  in  a  cavalry  regiment  in  the  Cuban  war,  doing  hard  riding.  He 
contracted  typhoid  fever,  and  during  the  illness  resulting  his  weight 
fell  from  140  to  109  pounds.  Shortly  after  convalescence,  before  he 
regained  his  lost  weight,  when  attempting  to  head  a  barrel  weighing 
500  pounds,  he  felt  something  give  way  in  the  old  cicatrix,  and  shortly 
afterward  noticed  a  small  bulging.  Examination  the  following  year 
showed  a  slight  recurrence  in  the  region  of  the  internal  ring.  I  re- 
operated  upon  him  in  April,  1901,  and  a  description  of  the  condition 
found  will  be  given  later. 

Case  IV. — P.  M.,  male,  aged  twenty  years,  was  operated  upon  in 
1893  for  a  right  inguinal  hernia.  The  wound  healed  by  primary 
union  and  he  remained  well  until  two  years  Idter,  when  he  received  a 
severe  kick  in  the  groin  during  a  fight.  A  very  slight  relapse  occurred 
in  the  canal  at  the  site  of  the  internal  ring.  A  truss  was  applied,  and 
little  more  than  exaggerated  impulse  has  been  noted  since. 

Case  V. — O.  S.,  male,  aged  twenty-three  years;  operated  upon 
September  7,  1898,  for  a  large,  reducible  inguinal  hernia.  Severe 
staphylococcus  suppuration  extending  to  the  deeper  layers  occurred. 
The  patient  remained  well  until  eighteen  months  later,  when,  on  lift- 
ing a  barrel  of  potatoes,  he  felt  something  give  way,  and  a  small  pro- 
trusion was  observed  in  the  canal. 

Case  VI. — J.  W.,  male,  aged  eighteen  years.  Operation  was  done 
in  1893  fo'"  ^  i"'g^t  inguinal  hernia.  The  patient  remained  well  for 
six  years,  at  the  end  of  which  time  a  slight  weakness  was  observed  in 
the  canal,  and  a  truss  applied. 

In  addition  to  these  6  cases  there  has  been  i  other  relapse  in 
a  case  operated  upon  by  the  house  surgeon  in  my  service  at  the 
Post-Graduate  Hospital.  The  patient  was  a  boy,  aged  four 
years.  Very  severe  and  prolonged  deep  suppuration  followed 
operation,  and  the  wound  was  four  months  in  healing.  Relapse 
occurred  six  months  after  operation. 

In  still  another  case,  in  which  Bassini's  operation  with  a  dif- 
ferent technique  was  employed,  relapse  occurred.    This  was  the 


352  COLEY, 

first  time  I  attempted  to  perform  Bassini's  method,  and  the 
operation  was  very  imperfectly  done.  Silk  was  used  for  the 
buried  sutures,  the  hernia  was  very  large,  and  the  operation 
prolonged.  Deep  suppuration  followed,  with  extrusion  of 
nearly  all  the  buried  sutures.  Relapse  followed  three  months 
afterward. 

Eliminating  the  last  2  cases,  inasmuch  as  they  do  not  prop- 
erly belong  to  the  main  series  of  cases  operated  upon  by  a  uni- 
form technique,  with  buried  absorbable  sutures,  we  have  but  6 
relapses  in  773  cases. 

Much  time  and  effort  have  been  spent  in  tracing  these  cases  to 
final  results. 

Eighteen  cases  of  inguinal  hernia  in  the  male  were  operated 
upon  without  transplantation  of  the  cord.  These  were  nearly 
all  early  cases,  operated  upon  between  the  years  1891  and  1893. 
In  6  of  these  cases  relapse  followed.  It  is  to  be  noted,  how- 
ever, that  two  of  these  cases  were  csecal  hernia. 

Direct  Hernia.  I  operated  upon  1 1  direct  hernia  in  seven 
individuals,  in  4  cases  the  hernia  being  double.  Bassini's 
method  was  employed  in  all  except  i,  and  in  this  the  cord  was 
not  transplanted. 

Relapsed  Cases  Cured  by  Second  Operation.  The  following  cases 
have  some  bearing  upon  the  question  of  operating  upon  cases 
that  have  once  relapsed  : 

Case  I. — V.  S.,  aged  nine  years.  Operation  by  Czerny's  method, 
with  silk,  January,  1892.  The  wound  healed  by  primary  union,  but 
in  a  {t'f^  weeks  a  small  sinus  formed,  and  some  of  the  silk  sutures  came 
out.  The  hernia  relapsed  in  about  four  months.  1  again  operated  by 
Bassini's  method  in  July,  1892,  using  kangaroo  tendon  for  the  buried 
sutures.  The  patient  is  at  present  free  from  recurrence,  nearly  nine 
years  later. 

Case  II. — F.  H.,  aged  ten  years,  was  operated  upon  February  10, 
1892,  by  Czerny's  method,  with  chromicized  catgut  for  the  buried 
sutures.  The  hernia  relapsed  in  three  years.  In  July,  1895,  I  again 
operated  ;  this  time  by  Bassini's  method,  with  kangaroo  tendon  for 
the  buried  sutures,  and  the  hernia  was  perfectly  sound  in  October, 
1900,  more  than  five  years  later. 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL    HERNIA.     353 

Case  III. — A.  B.,  male,  aged  twelve  years.  He  had  been  operated 
upon  by  Dr.  Bull  by  Czerny's  method,  non-chromicized  catgut  for  a 
double  inguinal  hernia,  February  4,  1893.  The  hernia  relapsed  on 
both  sides  within  two  months  after  operation.  On  April  11,  1893,  ^ 
operated  on  both  sides  by  Bassini's  method,  with  kangaroo  tendon 
sutures.  The  patient  was  perfectly  sound  when  last  observed,  April 
22,  1899,  or  six  years  after  the  secondary  operation. 

Case  IV. — W.  V.  S.,  aged  forty  years,  with  double  inguinal  hernia. 
This  case  is  of  very  great  interest,  inasmuch  as  the  operations  were 
performed  in  August,  1891,  nearly  ten  years  ago.  I  used  Bassini's 
method  on  the  right  side  and  Czerny's  on  the  left.  Both  sides  re- 
mained firm  until  the  fall  of  1900,  or  nine  years  after  operation,  when 
the  left  side  recurred  in  the  canal.  I  operated  for  the  recurrence  one 
week  ago,  this  time  by  Bassini's  method.  The  right  side  remains  per- 
fectly sound. 

I  have  operated  upon  a  number  of  other  patients  for  relapse 
following  other  methods  of  operation,  but  the  cases  are  more 
recent,  and  hence  of  less  interest.  The  only  operation  for 
relapse  foUovi^ing  Bassini's  method  that  I  have  performed  was 
done  a  week  ago  upon  the  patient  operated  upon  seven  years 
ago  and  in  whom  the  relapse  was  due  to  heavy  lifting  after 
enormous  loss  of  weight  from  an  attack  of  typhoid  fever.  In 
this  case  I  found  the  union  of  the  aponeurosis  absolutely  firm  ; 
the  recurrence  had  taken  place  at  the  internal  ring,  and  consisted 
merely  of  a  dilatation  of  the  space  left  for  the  cord  to  emerge. 
There  was  no  sac,  but  a  bulging  of  the  peritoneum  into  the 
space  referred  to,  and  dissecting  ofif  for  a  small  area  the  apo- 
neurosis from  the  underlying  internal  oblique  muscle.  The  cord 
was  rather  adherent  to  the  aponeurosis  and  oblique  muscle,  but 
was  separated,  and  Bassini's  operation  was  again  performed, 
leaving  a  very  normal  opening  for  the  cord  at  the  internal  ring. 

The  superiority  of  Bassini's  method  is  further  confirmed  by 
the  splendid  results  obtained  at  the  clinic  of  Professor  Carle,  as 
reported  by  Galeazzi.' 

'  "  Risultati  definitive  nella  cura  operativa  del  I'ernia  inguinale,"  by  Galeazzi.  Estratto 
della  clin.  Chir.,  1899,  No.  6. 

Am  Surg  23 


354  COLEY, 

During  the  ten  years  between  1889  and  1899,  1400  operations 
for  the  radical  cure  of  hernia  were  performed  at  the  clinic  upon 
1285  patients,  with  but  two  deaths,  and  one  of  these  occurred 
as  a  result  of  pneumonia  on  the  seventh  day  after  operation. 
Bassini's  method  was  employed  in  11 20  of  these  1400  opera- 
tions ;  Kocher's  in  the  remaining  280.  Efforts  were  made  to 
trace  the  cases,  and  it  was  ascertained  that  in  840,  in  which 
upward  of  two  years  had  passed  between  operation  and  exam- 
ination, 792,  or  94.29  per  cent.,  remained  perfectly  sound  ;  while 
48,  or  5.71  per  cent.,  showed  a  recurrence. 

Galeazzi  collected  a  further  series  of  1334  cases  of  hernia 
operated  upon  according  to  Bassini  by  surgeons  outside  of  Italy, 
which  showed  but  2.16  per  cent,  of  relapses. 

The  importance  of  primary  wound-healing  in  effecting  a  per- 
manent cure  is  well  illustrated  by  the  cases  observed  at  Carle's 
clinic.  Of  128  cases  of  secondary  wound-healing  10,  or  7.9 
per  cent.,  relapsed ;  and  of  these  relapse  occurred  during  the 
first  year  in  7 ;  during  the  second  year  in  2,  and  after  two  years 
in  but  I,  thus  demonstrating  that  relapse  is  far  more  likely  to 
occur  during  the  first  year  after  operation  than  later. 

In  84  cases  of  voluminous  hernia,  Galeazzi  states  there  were 
but  2  relapses.  At  the  same  time  he  points  out  the  danger  of 
operating  upon  very  large  irreducible  herniae. 

Galeazzi  considers  Bassini's  method  more  logical,  more  sur- 
gical, and  more  secure  than  Kocher's,  and  believes  that  the 
superiority  of  the  method  is  especially  shown  in  cases  in  which 
the  canal  is  not  straight,  since  the  obliquity  of  the  canal  favors 
its  closure  at  the  moment  when  the  intra-abdominal  pressure  is 
exerted  or  increased,  and  to  this  fact  he  ascribes  the  excellent 
results  that  have  been  obtained  by  Bassini's  method. 

Dr.  De  Garmo,  of  New  York,  has  operated  upon  612  cases, 
with  but  8  relapses. 

The  large  statistics  of  Dr.  Bull,  though  not  published  up  to 
date,  still  further  confirm  the  superiority  of  this  method. 

During  the  period  from  1891  to  1901  I  have  operated  upon 
845  cases  of  inguinal  hernia  and  femoral  hernia.  Of  these  791 
were  operations  for  inguinal  hernia,  773  of  which  were  operated 


RADICAL  CURE   OF    INGUINAL  AND   FEMORAL    HERNIA.     355 

upon  by  Bassini's  method,  with  the  substitution  of  silk  by  kan- 
garoo tendon  for  the  buried  sutures ;  54  were  operations  for 
femoral  hernia,  with  but  i  relapse. 

Five  hundred  cases  of  inguinal  hernia,  operated  upon  by 
Bassini's  method,  were  traced  from  one  to  nine  years,  with  6 
relapses.  Of  155  cases  of  inguinal  herniae  in  the  female,  84 
were  traced  from  one  to  eight  years  after  operation,  without  a 
single  relapse. 

Of  the  54  cases  of  femoral  hernia,  31  were  well  from  one  to 
nine  years  after  operation. 

Of  the  inguinal  herniae  operated  upon  by  Bassini's  method, 
10  were  well  from  eight  to  nine  years  after  operation  ;  13,  from 
seven  to  eight ;  23,  from  six  to  seven ;  26,  from  five  to  six ;  54, 
from  four  to  five  ;  89,  from  three  to  four ;  104,  from  two  to  three ; 
178,  from  one  to  two. 


356  DISCUSSION. 


DISCUSSION. 

Dr.  J.  Collins  Warren,  of  Boston. 

I  wish  to  thank  Dr.  Coley  for  his  very  valuable  work  in  placing  his 
operations  on  a  sound  basis,  as  it  is  a  standard  which  we  now  can  go 
by.  We  all  concede  the  operation  to  be  a  success,  and  nearly  all  the 
cases  are  cured,  there  being  very  little  difficulty  in  getting  healing  by 
first  intention.  There  remains,  however,  certain  details  of  interest, 
and  one  is  age.  The  question  of  operation  in  infancy  is  an  interest- 
ing one,  and  what  shall  be  our  decision  in  any  given  case  is  an 
important  one.  The  tendency  is  to  operate  much  more  now  than 
formerly  ;  but  sometimes  even  up  to  the  age  of  twenty-one  we  may  get 
a  radical  cure  by  a  truss.  I  have  seen  such  cases  which  have  gotten 
entirely  well,  and  have  also  seen  some  in  young  men  who  have  grown 
up  with  a  truss,  and  then  had  to  be  operated  upon  afterward.  I  had 
to  operate  recently  on  a  young  man  whom  I  had  treated  in  childhood 
with  a  truss  with  apparent  success.  Athletic  exercises  are  very  hard 
on  the  inguinal  canal.  As  an  example  of  what  a  tremendous  strain 
may  be  borne  I  might  mention  the  case  of  an  athlete  upon  whom  I 
operated  several  years  ago.  Seeing  a  man  about  to  drop  a  trunk  he 
rushed  to  his  aid,  seized  the  trunk  and  saved  it,  but  ruptured  himself 
on  the  sound  side  without  reproducing  his  old  hernia  on  the  other 
side. 

I  recall  the  case  of  a  grocer  upon  whom  I  operated  several  years 
ago,  who  told  me  that  he  had  had  no  recurrence,  although  he  was  in 
the  habit  of  carrying  several  barrels  of  flour  daily  up  two  flights  of 
stairs. 

Then  as  to  the  other  extreme  of  life.  I  have  a  man,  aged  seventy 
years,  on  whom  I  would  like  to  operate,  but  question  the  advisability 
of  attempting  relief  in  this  way  unless  there  be  urgent  need. 

As  to  sepsis,  I  believe  we  all  have  had  more  or  less  of  this  in  the 
beginning,  but  very  much  less  now  than  in  the  past.  I  do  not  attribute 
this  so  much  to  the  use  of  gloves  as  to  the  final  preparation  of  the 
patient  immediately  before  the  operation,  which  is  most  important. 

As  to  absorbable  sutures,  the  question  is,  what  is  and  what  is  not  an 
absorbable  suture.  Certain  forms  of  chromicized  animal  suture  have 
to  be  removed  after  long  intervals,  and  I  do  not  think  that  chromi- 


RADICAL  CURE   OF    INGUINAL  AND  FEMORAL  HERNIA.     357 

cized  absorbable  sutures  are  any  more  absorbable  than  silk.  Person- 
ally I  get  better  results  with  silk  which  may  be  boiled  five  minutes 
before  operation.  I  do  not  approve  of  any  method  which  involves 
metallic  sutures.     I  do  not  regard  silk  in  the  nonabsorbable  class. 

Dr.  W.  S.  Halsted,  of  Baltimore. 

I  consider  this  paper  justifies  the  great  credit  Bassini  deserves  for 
his  operation.  I  have  not  been  in  the  habit  of  dividing  the  internal 
oblique  muscle  during  the  last  few  years,  and  yet  our  results  are  just  as 
good  as  could  be  obtained.  I  believe  the  tendency  should  be  to 
simplify  the  operation.  The  recurrences  that  we  have  had  were  in 
cases  where  the  veins  had  not  been  removed.  It  seems  to  be  a  very 
rational  procedure,  and  we  have  not  had  a  single  recurrence  when 
they  have  been  removed.  Lately  we  have  not  been  transplanting  the 
cord,  and  we  no  longer  get  atrophy  of  the  testicle  after  removing  the 
veins.     Of  course  we  leave  the  vas  deferens  in  place. 

As  to  silver  wire,  we  have  been  very  much  interested  in  it  ever  since 
we  have  used  it,  because  we  cannot  see  such  results  as  others  get.  We 
have  been  over  all  of  our  cases  this  spring,  and  we  find  we  have  closed 
up  520  cases  with  silver  wire  out  of  780  cases  operated  on.  Our 
assistants  report  that  they  do  not  see  quite  the  same  healing  of  the 
skin.  2614  sutures  were  used  in  the  cases  reported,  and  there  were 
25  cases  of  suppuration,  which  is  a  larger  percentage  than  that  reported 
by  Dr.  Coley.  Where  there  is  a  hemorrhage  and  we  let  out  any 
blood  we  call  it  a  suppuration,  and  if  we  only  have  one  drop  of  pus 
we  call  it  the  same.  We  have  removed  from  suppurating  wounds  two 
sutures,  and  these  were  in  two  cases.  Of  sutures  removed  after  leaving 
the  hospital  there  were  three  ;  sutures  removed  for  secondary  stitch 
abscess  in  which  the  wound  had  healed  primarily,  none;  sutures  re- 
moved for  pain,  one,  and  this  was  in  the  case  of  a  man  who  was 
neurasthenic ;  cases  of  secondary  stitch  abscess  after  leaving  the 
hospital,  one,  but  no  suture  was  removed,  and  the  abscess  healed.  In 
appendicitis  wire  was  used  in  227  cases,  necessitating  nearly  1000 
sutures.  In  16  cases,  which  include  all  abscess  cases,  there  was  some 
suppuration  about  the  packing,  but  stitches  were  only  removed  in  four 
cases ;  sutures  removed  after  leaving  the  hospital,  one ;  sutures  re- 
moved for  pain,  five,  but  we  are  quite  sure  that  they  had  nothing  to 
do  with  the  pain.  1  do  not  know  of  a  single  case  where  the  removal 
of  the  suture  relieved  the  pain. 


358     RADICAL  CURE   OF   INGUINAL  AND  FEMORAL   HERNIA. 

Dr.  Coley.  As  to  the  age  question,  raised  by  Dr.  Warren,  I  would 
state  that  I  have  operated  on  people  over  seventy  years  of  age,  but  I 
do  not  think  it  should  be  a  routine  measure  above  fifty  or  sixty. 

As  to  the  question  of  absorbable  sutures  I  have  not  much  to  add. 
As  to  silk,  in  the  cases  of  sinus  formation  that  I  have  observed  silk 
has  been  the  least  offender.  It  is  true  that  kangaroo  tendon  or  catgut 
may  be  so  chromicized  as  to  remain  unabsorbed  for  a  long  time, 
but  that  would  put  it  in  the  class  that  I  call  non-absorbable  sutures. 
Concerning  silver  wire,  a  considerable  number  of  these  cases  of  sinus 
formation  have  been  where  wire  was  used.  In  a  certain  proportion 
the  wound  had  healed  by  primary  union. 

It  is  not  always  the  hospital  in  which  the  operation  was  performed, 
or  the  surgeon  who  operated  on  them,  that  see  the  returned  cases  with 
sinuses.  Most  of  the  cases  that  I  have  observed  had  not  been  back  to 
the  surgeon  who  operated,  and  he  was  therefore  not  in  a  position  to 
state  that  a  good  result  did  not  follow  the  original  operation. 

Dr.  Halsted  himself  reports  enough  cases,  I  think,  to  justify  us  in 
abandoning  silver  wire  as  a  buried  suture  in  hernia  operations,  if  we 
can  show,  as  I  think  we  have,  that  equally  as  good  or  better  results  as 
regards  radical  cure  can  be  obtained  with  absorbable  sutures. 


TREATMENT   OF   AORTIC   ANEURISMS  BY   MEANS 

OF  SILVER  WIRE  AND    ELECTRICITY; 

WITH    REPORT  OF    CASES. 


By  LEONARD  FREEMAN,   M.D., 

DENVER,    COL. 


The  literature  of  this  subject  has  been  so  thoroughly  col- 
lected and  studied  by  D.  D.  Stewart  and  Guy  L.  Hunner.  in 
their  recent  elaborate  papers,'  that  it  is  unnecessary  for  me  to 
go  over  the  ground  again.  I  shall  merely  mention  a  few  promi- 
nent points : 

The  method  of  treating  aneurisms  of  the  aorta  by  means  of 
a  fine  wire  introduced  through  a  hollow  needle  and  coiled 
within  the  sac  was  first  suggested  and  carried  out,  in  1864, 
by  Charles  H.  Moore,  of  the  Middlesex  Hospital.  Corradi,  in 
1879,  added  much  to  the  effectiveness  of  the  procedure  by 
passing  a  strong  galvanic  current  through  the  wire,  thus  pro- 
moting more  rapid  and  firm  coagulation.  It  has  hence  been 
designated  the  "  Moore-Corradi  Operation."  D.  D.  Stewart,  of 
Philadelphia,  has  done  more  than  anyone  else  to  bring  the 
operation  into  prominence,  perfect  its  technique,  and  empha- 
size its  possibilities. 

There  have  been  reported,  according  to  Hunner,  of  Johns 
Hopkins,  14  cases  in  which  wire  alone  was  used,  with  3  recov- 
eries, although  one  patient  subsequently  died  from  rupture 
of  the  aorta  below  the  tumor,  and  23  cases  in  which  both  wire 
and  galvanism  were   employed,  with   4  recoveries.     In  all  37 

'  Hunner,  Johns  Hopkins  Hospital  Bulletin,  November,  1900;  Stewart.  American 
Journal  of  the  Medical  Sciences,  October,  1892;  Ibid.,  August,  1896;  Philadelphia 
Medical  Journal,  November  12, 189S. 


360  FREEMAN, 

cases,  with  7  recoveries.  There  have  also  been  a  number  of 
encouraging  improvements. 

Apparently  this  is  not  a  brilliant  showing,  but  it  must  be 
borne  in  mind  that  many  of  the  aneurisms  were  extremely 
unfavorable  for  operation.  In  some  instances  the  sac  was  fusi- 
form, or  had  several  compartments,  or  was  on  the  point  of 
bursting;  while  in  others  the  patients  were  nearly  dead  from 
exhaustion  or  from  pressure  upon  the  trachea  ;  and  occasionally 
a  poor  technique  seems  to  have  been  directly  at  fault.  Failure, 
under  such  circumstances,  cannot  excite  surprise,  and  it  must 
not  be  lost  sight  of  that  no  other  treatment  can  furnish  results 
at  all  comparable  to  these. 

To  obtain  the  best  results,  it  seems  evident  that  the  cases 
should  be  carefully  selected.  The  aneurism  should  be  sac- 
culated, not  fusiform,  without  too  large  an  opening,  and  with 
but  one  compartment.  It  should  not  have  progressed  too  far 
toward  rupture,  and  the  patient  should  have  sufficient  vitality 
to  enable  him  to  live  through  the  tedious  process  of  cure.  It 
is  scarcely  necessary  to  state  that  the  operation  is  practically 
confined  to  aneurisms  not  amenable  to  other  surgical  procedures 
— /.  e.,  aneurisms  of  the  abdominal  aorta,  the  thoracic  aorta,  the 
innominate  artery,  etc.,  the  first  named  requiring  a  preliminary 
coeliotomy. 

An  accurate  diagnosis  is  of  the  utmost  importance,  but  in 
spite  of  the  greatest  care,  mistakes  are  apt  to  occur.  We  will 
hope,  however,  that  when  the  operation  comes  into  more  gen- 
eral use,  better  methods  of  investigation  will  arise.  Perhaps 
the  X-ray  may  be  of  service,  as  insisted  upon  by  Dudley  Tait, 
of  San  Francisco. 

In  addition  to  reporting  two  cases  of  my  own,  my  object  is 
to  discuss  several  points  pertaining  to  the  technique,  which, 
according  to  Stewart,  is  briefly  as  follows :  Asepsis,  local  anaes- 
thesia, insertion  into  the  aneurism  of  an  insulated  hollow 
needle  through  which  is  introduced  silver  wire  (about  No.  27). 
It  must  be  well  drawn  and  wound  on  a  spool,  to  increase  its 
tendency  to  coil,  and  from  three  to  twenty  feet  in  length, 
according  to  the  size  of  the  cavity.     The  wire  is  then  attached 


TREATMENT  OF  AOKTIC  ANEURISMS.        36 1 

to  the  positive  pole  of  a  galvanic  battery,  the  negative  electrode, 
large  and  well  moistened,  being  applied  to  the  back,  and  a 
current  of  70  to  80  ma.  passed  for  from  half  an  hour  to  an  hour 
and  a  half.  The  wire  is  then  cut  close  to  the  skin  and  sunk 
beneath  the  surface. 

Let  us  consider  in  detail  some  of  the  questions  involved  : 

Character  of  the  Wire.  Most  operators  agree  that  silver 
wire  is  preferable  to  any  other.  It  is  easily  obtained,  inexpen- 
sive, is  a  good  transmitter,  and  becomes  sufficiently  corroded  by 
the  passage  of  the  electric  current  to  insure  adhesion  of  the  clot. 
Steel  is  said  to  be  too  brittle,  and  soft  iron  too  easily  disinte- 
grated. The  wire  should  be  fine,  about  No.  27,  because  fine 
wire  coils  more  readily  and  offers  less  resistance  to  electricity 
and  to  contraction  of  the  sac.  Silver  wire  varies  much  in  elas- 
ticity, according  to  the  amount  of  copper  which  it  contains  and 
the  degree  to  which  it  is  drawn.  Hunfter  lays  great  stress 
upon  the  use  of  highly-drawn  wire  (from  No.  8  to  No.  27),  con- 
taining seventy-five  parts  of  copper  to  the  thousand,  making  it 
so  hard  and  springy  that  it  readily  retains  the  coil  imparted  to 
it.  Stewart  also  insists  upon  the  use  of  wire  which  has  been 
drawn,  and  both  he  and  Hunner  strongly  advise  winding  the 
wire  upon  a  spool  before  inserting  it.  These  ideas  are  founded 
upon  the  manner  in  which  various  kinds  of  wire  deport  them- 
selves when  introduced  into  glass  flasks.  They  claim  that  much 
can  be  learned  in  this  way  regardmg  the  behavior  of  wire  in  an 
aneurism,  and  that  it  is  better  no  one  should  operate  upon  the 
living  until  numerous  experiments  of  this  kind  have  been 
made. 

Hunner,  in  his  beautifully  illustrated  article,  shows  how  ordi- 
nary undrawn  silver  wire  arranges  itself  in  large  circles  around 
the  periphery  of  a  flask  without  filling  the  centre  ;  while  his 
highly-drawn,  elastic  wire  coils  itself  in  the  middle  of  the 
receptacle.  (These  experiments  were  made  by  Hunner  and 
Finney  in  the  laboratory  of  the  Johns  Hopkins  Hospital.) 

It  is  somewhat  questionable,  however,  whether  it  is  advisable 
to  have  most  of  the  wire  in  the  centre  and  comparatively  little 
in   contact  with  the  walls  of  an  aneurism.     The   firmness  of  a 


362  FREEMAN, 

clot,  its  Stability,  and  its  capacity  for  organization  must  depend 
somewhat  upon  the  support  derived  from  mural  implantation. 
A  clot  suspended  in  the  centre  of  the  sac  would  be  of  little 
use,  however  satisfactory  its  consistency.  In  addition,  we  must 
not  forget  that  an  aneurism  cures  itself  by  the  deposition  of 
clots  about  its  circumference,  and  that  the  electrolytic  effect  of 
galvanism  upon  the  sac,  as  demonstrated  by  Macewen,  promotes 
the  accumulation  of  leukocytes  and  the  formation  of  firm, 
white,  readily  organizing  coagula. 

But,  aside  from  these  more  or  less  theoretical  considerations, 
it  occurred  to  me  that  glass  flasks  do  not  represent  actual  con- 
ditions,and  that  we  can  draw  no  reliable  conclusions  from  their 
employment.  In  repeating  Hunner's  experiments,  which  I  did 
with  wire  obtained  directly  from  him,  as  well  as  with  ordinary 
silver  wire,  both  drawn  and  undrawn,  I  found  that  the  strands 
slipped  easily  about  within  the  smooth,  hard,  glass-lined  cavity, 
and  arranged  themselves  always  in  a  definite  manner,  as  he  has 
described.  The  inside  of  an  aneurism,  however,  is  not  hard 
and  smooth  ;  it  is  often  irregular  and  coated  with  more  or  less 
rough  layers  of  clot,  so  that  the  wire  would  easily  catch  and  be 
deflected  from  its  natural  course.  Also,  the  coils  could  not 
rotate  within  the  cavity  and  adjust  themselves  when  pushed 
upon  by  the  entrance  of  a  fresh  portion,  as  occurs  in  a  flask. 

In  order  to  represent  more  accurately  the  conditions  as  they 
really  exist,  I  obtained  a  large  Colorado  turnip,  the  size  and 
shape  of  a  flask  of  500  c.c.  This  I  hollowed  out  through  an 
opening  large  enough  to  observe  what  took  place  within. 
The  walls  were  of  the  consistency  of  an  old,  firm  clot,  and  of 
about  the  right  irregularity  and  roughness.  After  running  a 
hollow  needle  through  the  side  of  tiiis  "aneurism,"  I  inserted 
various  kinds  of  wire.  My  observations  convinced  me  that 
the  glass-flask  method  had  led  to  erroneous  and  misleading 
conclusions.  Ordinary  undrawn  silver  wire,  under  these  new 
conditions,  coiled  itself  backward  and  forward  and  around 
through  the  cavity,  not  only  covering  the  walls  to  a  satisfactory 
extent,  but  filling  the  centre  also — totally  different  from  its  con- 
duct in  a  flask.     Even  wire  not  previously  coiled  did  almost  if 


TREATMENT    OF    AORTIC     ANEURISMS.  363 

not  quite  as  well  in  this  regard.  The  stiff,  springy  wire  ob- 
tained from  Dr.  Hunner  formed  a  good  network  also,  but 
not  so  good  as  the  ordinary  wire.  The  meshes  were  not  so 
evenly  distributed  over  the  walls  and  centre ;  and  when  the 
wire  had  been  wound  upon  a  large  spool  it  was  still  less 
effective,  quite  large,  open  spaces  being  left  within  the  curl-like 
rings. 

When  the  needle  was  directed  away  from  the  opening  there  was 
little  or  no  tendency  on  the  part  of  the  ordinary  wire  to  escape 
through  it ;  but  a  coil  or  an  end  of  the  Hunner  wire  would  often 
spring  suddenly  through  the  hole,  like  a  jack-in-a-box.  I  feel 
that  a  real  danger  lurks  in  these  sudden  movements,  from  dis- 
lodgement  of  clots,  penetration  of  the  aorta,  etc.  The  phenome- 
non was,  of  course,  still  more  marked  when  the  needle  was 
directed  toward  the  opening.  Through  a  trap-door  in  the 
turnip  I  was  able  to  extract  the  coils  without  disarranging  them. 
I  observed  that  a  coil  of  ordinary  soft  wire  could  easily  be 
squeezed  together  in  the  hand,  and  that  it  remained  as  it  was 
moulded,  while  a  coil  of  drawn  and  alloyed  wire  (Hunner)  was 
so  springy  that  it  resumed  its  original  shape  as  soon  as  the 
pressure  was  removed. 

These  experiments  convinced  me  that  Hunner  and  others 
are  mistaken  in  their  deductions.  Instead  of  hard,  elastic  wire 
being  superior  to  the  ordinary  soft  variety,  the  advantage  lies 
just  the  other  way.  The  elastic  wire  really  possesses  certain 
disadvantages — it  kinks  in  a  more  anno)'ing  manner  and  breaks 
more  readily;  it  does  not  coil  so  satisfactorily  within  an 
aneurism  ;  it  is  more  liable  to  protrude,  sometimes  with  force, 
through  the  aortic  opening;  its  sudden  movements  during 
introduction  may  dislodge  dangerous  clots  ;  and  its  inherent 
springiness  would  tend  to  prevent  contraction  of  the  sac  wall, 
although  I  do  not  lay  so  much  stress  upon  this  as  do  some. 
Soft,  unalloyed  silver  wire  has  another  advantage  over  the 
harder  variety  in  that  it  more  rapidly  loses  in  size  under  the 
influence  of  the  electric  current,  and  becomes  much  rougher 
and  more  brittle.  I  found  this  difference  quite  marked  in  a 
seance  of  but  twenty  minutes.     Wire  thus  acted  upon  breaks 


364  FREEMAN, 

and  crumbles  to  pieces  readily,  and  can  offer  no  appreciable 
resistance  to  contraction. 

In  the  course  of  my  experiments  I  noticed  another  point  of 
some  importance.  If  the  canula  is  inserted  too  far  into  the 
sac,  as  we  are  apt  to  insert  it,  the  wire  has  a  strong  tendency 
to  curl  up  against  the  further  wall,  leaving  a  more  or  less  clear 
space  surrounding  the  place  of  entrance — a  spot  which  often 
needs  strengthening  more  than  others.  This  may  be  avoided 
by  just  penetrating  the  aneurism  with  the  needle,  and  no  more. 

Quantity  of  Wire  to  Be  Used.  Stewart,  Hunner.  and 
others  confidently  assume  that  it  is  far  better  to  employ  a  small 
amount  of  wire  (from  three  to  ten  feet,  or,  at  most,  twenty  feet) 
than  a  large  amount. 

They  are  so  sure  of  this  that  they  attribute  some  of  the  fail- 
ures which  have  occurred  to  a  disregard  of  this  principle.  Their 
theory  is  based  upon  the  following  considerations:  (i)  Large 
amounts  of  wire  are  unnecessary,  smaller  pieces  producing  clots 
which  are  just  as  satisfactory.  (2)  Much  wire  tends  to  prevent 
contraction  of  the  sac  wall,  upon  which  depends  the  cure.  (3) 
The  reported  recoveries  were  obtained  with  small  amounts  of 
wire. 

At  first  sight  these  points  appear  convincing,  but  upon  closer 
inspection  it  develops  that  both  reasoning  and  conclusion  are 
open  to  question. 

It  seems  sufficiently  evident  that  the  greater  the  quantity  of 
wire  used  the  more  certainly  and  quickly  will  a  clot  form,  and 
the  more  firm  and  lasting  will  it  be,  lodged,  as  it  is,  among  the 
meshes  of  the  wire  ;  in  fact,  if  every  portion  of  the  sac  could 
be  filled  completely  with  wire  there  would  be  no  room  for 
blood  at  all,  and  the  aneurism  as  such  would  cease  to  exist. 

Aneurisms  are  definitely  cured  by  the  gradual  replacement 
of  coagula  by  fibrous  tissue,  which  slowly  but  firmly  contracts. 
The  contractile  power  of  such  a  mass  is  certainly  considerable, 
as  is  seen  in  scar-tissue  in  other  portions  of  the  body,  and  is  not 
to  be  seriously  impeded  by  the  presence  of  a  more  or  less  loose 
coil  of  fine  silver  wire,  especially  if  the  wire  be  soft  and  devoid 
of  spring.     This  can  be  more  clearly  appreciated  after  crushing 


TREATMENT    OF    AORTIC    ANEURISMS.  365 

such  a  coil  in  the  hand,  Hunner  and  Stewart  admit  the  power 
of  this  contractile  force  when  they  assert  that  it  is  dangerous 
to  use  steel  wire,  because  of  the  likelihood  of  its  breaking  and 
penetrating  the  sac  wall.  If  steel  wire  can  be  broken,  soft  silver 
wire  can  certainly  be  easily  bent  into  a  small  compass. 

But  even  admitting  that  contraction  would  be  to  a  certain  ex- 
tent impeded,  it  is  hard  to  see  what  actual  harm  would  be  done 
in  the  presence  of  a  firm,  well-organized  clot.  To  be  sure,  con- 
traction would  sooner  reach  its  limit,  a  larger  bunch  of  tissue 
remaining;  but  as  long  as  this  consisted  of  closely  coiled  wire, 
connective  tissue  and  fibrin,  no  objection  could  be  made  to  its 
mere  presence.  It  can  here  be  clearly  appreciated  that  soft, 
undrawn  wire  would  possess  a  decided  advantage  over  that 
which  is  hard  and  springy,  as  the  latter  would  cause  a  continu- 
ous centrifugal  pressure. 

It  is  true  that,  the  reported  cures  have  been  obtained  in  cases 
where  small  amounts  of  wire  were  used ;  but  this  fact  is  mis- 
leading, as  is  shown  by  a  glance  at  the  records  as  given  by  Hun- 
ner himself.  According  to  these,  wiring  has  been  resorted  to 
thirty-seven  times,  much  wire  being  employed  in  but  seven  in- 
stances, i.  e.,  78  feet,  75  feet  (in  two  sittings),  32  feet,  33  feet, 
225  feet,  150  feet,  and  32  feet  (in  three  sittings).  It  is,  however, 
questionable  whether  such  lengths  as  32  and  33  feet  should  be 
considered  as  "  much"  wire  when  we  remember  that  both  Stewart 
and  Hunner  recommend  as  high  as  20  feet  under  certain  circum- 
stances. The  figures  would  then  stand  33  to  4.  For  the  sake  of 
argument,  however,  we  shall  assume  that  much  wire  has  been 
used  in  7  cases  and  a  small  amount  in  30.  But  4  of  these  7  cases 
must  be  excluded  because  of  features  rendering  their  considera- 
tion absolutely  unfair.     They  are  as  follows  : 

Moore's  case  (78  feet)  died  of  sepsis. 

Cayley's  case  (75  feet),  two  sacs,  with  a  very  large  opening 
into  the  main  vessel. 

White  and  Gould's  case  (32  feet),  two  sacs,  fusiform  aneurism  ; 
death  from  sloughing  due  to  pressure  from  without. 

Abbe's  case  (150  feet),  reversed  current  in  middle  of  sitting, 
and  probably  softened  clot  already  formed. 


366  FREEMAN, 

This  leaves  but  3  cases,  one  in  which  33  feet  were  used,  one 
32  feet,  and  one  225  feet — /,  e.: 

Hulke's  case  (33  feet),  "desperate  condition,"  wire  did  not 
fill  entire  sac,  which  continued  to  expand  in  empty  portion.  If 
this  case  shows  anything,  it  is  that  not  enough  wire  was  used. 

Finney's  case  (32  feet,  in  three  sittings).  No  autopsy,  and 
hence  we  know  nothing  of  the  real  condition  of  things  within. 

Roosevelt's  case  (225  feet)  improved,  the  tumor  becoming 
firmer.     Died  on  twenty-second  day,  probably  of  embolism. 

It  is  thus  seen  that  a  really  large  amount  of  wire  (225  feet)  has 
been  used  in  but  one  case  which  can  be  called  at  all  favorable,  and 
in  this  the  patient  lived  twenty-two  days,  finally  dying  of  what 
appeared  to  be  embolism — an  accidental  complication.  In  the 
meantime  the  patient  had  improved,  and  the  tumor  grown  more 
firm. 

Hence  we  are  forced  to  conclude  that  the  employment  of  con- 
siderable wire  within  reason  has  some  theoretical  advantages, 
without  counterbalancing  disadvantages,  and  that  it  has  never 
been  given  a  fair  trial,  the  question  of  "  much  wire  or  little  wire" 
still  remaining  an  open  one. 

Strength  of  Current.  Stewart  and  others  insist  upon  the 
use  of  rather  a  strong  current — about  70  to  80  ma.,  as  a  rule. 
Hunner  objects  to  this,  regarding  it  as  dangerous  from  disinte- 
gration of  the  sac  wall,  or  even  of  the  aorta  itself  in  case  of 
misplacement  of  the  wire.  Hunner  claims  to  have  demonstrated 
by  his  experiments  that  a  current  of  lo  ma.  continued  for  fif- 
teen or  twenty  minutes  produces  practically  as  large  and  effec- 
tive a  clot  as  one  of  lOO  ma.  used  for  a  much  longer  period. 
This  seems  hardly  probable  on  the  face  of  it,  and,  in  addition, 
in  one  of  my  operations,  coagulation  did  not  occur,  as  evidenced 
by  the  movements  of  the  needle  for  some  thirty  minutes  after 
the  beginning  of  the  operation.  Hunner's  experiments  were 
made  in  rapidly  moving  blood  in  a  dog's  aorta.  Under  such 
conditions  we  know  that  clotting  of  blood  is  difficult  to  obtain, 
as  shown  by  several  autopsies  in  which  wire  accidentally  intro- 
duced into  the  aorta  remained  perfectly  clean.  And  it  must 
also  be  considered  that  where  the  circumference  of  the  clots  is 


TREATMENT    OF    AORTIC    ANEURISMS.  367 

SO  small  relative  differences  are  hard  to  estimate,  which  in  larger 
clots  would  be  quite  marked.  Such  an  experiment  is  hardly  a 
fair  test. 

In  my  opinion  more  accurate  data  can  be  obtained  by  em- 
ploying coagulated  blood,  because  in  aneurisms  the  blood  does 
not  move  with  anywhere  near  the  rapidity  that  it  does  within 
the  aorta  ;  and,  in  addition,  it  has  been  noted  in  many  operations 
that  blood  often  clots  shortly  after  turning  on  the  electric  cur- 
rent ;  hence  we  often  operate,  not  only  in  comparatively  stag- 
nant blood,  but  even  in  a  coagulum. 

It  will  also  be  admitted,  I  am  sure,  that  the  solid  clot,  which 
is,  as  it  were,  burned  on  to  the  wire,  counts  for  much  more  in 
the  ultimate  result  than  the  soft  coagulum  which  may  form 
around  it.  I  found  by  conducting  my  experiments  in  clotted 
blood  that  the  diameter  of  the  area  acted  on  by  a  current  of  100 
ma.  was  several  times  greater  than  that  effected  by  a  current  of 
10  ma.  during  the  same  length  of  time — twenty  minutes. 

The  danger  of  injuring  the  aorta  or  the  sac-wall  by  a  current 
of  70  or  80  ma.  is  probably  very  remote  (so  far  as  known  it  has 
never  occurred),  and  is  more  than  counterbalanced  by  the 
advantages  obtained. 

(As  a  mere  matter  of  interest,  in  blood  prevented  from  coag- 
ulating by  the  addition  of  sulphate  of  magnesia,  I  was  able  to 
produce  but  a  small  amount  of  coagulum  closely  adherent  to 
the  wire,  and  I  could  detect  little  if  any  difference  between  the 
effects  of  currents  of  high  power  and  those  of  low  power.) 

According  to  both  Stewart  and  Hunner,  the  chief  danger  in 
operating  upon  aneurisms  with  wire  is  the  clotting  of  the  blood 
in  but  a  portion  of  the  sac,  thus  exposing  the  remainder  to 
increased  pressure  and  possible  rupture.  This  hypothesis, 
however,  does  not  seem  reasonable.  A  sacculated  aneurism, 
according  to  the  size  of  its  opening,  contains  a  more  or  less 
comparatively  quiescent  pool  of  blood.  When  this  pool  is 
struck  by  an  impulse  from  the  heart  as  it  passes  through  the 
aorta  it  expands,  and  this  expansion,  so  say  the  laws  of  hydro- 
statics, is  equal  in  all  directions.  If  a  clot  forms  in  a  portion  of 
the  cavity,  this  does  not   increase   the   pressure    upon   the   re- 


36S  FREEMAN, 

mainder  of  the  wall.  It  does  not  even  increase  the  general 
blood-pressure,  because  nothing  is  added  to  the  total  quantity 
of  blood — in  fact,  the  general  blood-pressure,  together  with  that 
in  the  aneurism,  is  often  lowered  by  the  considerable  loss  of 
blood  which  may  take  place  during  the  operation. 

In  order  to  convince  myself  thoroughly  on  this  point,  I  fas- 
tened a  rubber  glove  to  a  fountain  syringe  filled  with  water,  and 
elevated  the  syringe.  The  glove  represented  an  aneurism,  and 
the  force  of  the  water  in  the  douche-bag  took  the  place  of  the 
pressure  of  the  blood,  this  force  being  measurable  by  the  height 
to  which  a  fine  stream  of  water  was  projected  through  a  hole  in 
one  of  the  glove-fingers.  After  the  insertion  of  a  large  solid 
body  within  the  glove,  to  represent  a  clot,  it  was  noticed  that 
the  stream  was  projected  to  exactly  the  same  height  as  before, 
thus  demonstrating  that  there  was  absolutely  no  increase  of 
pressure. 

Conclusions,  i.  Considering  the  inefificiency  of  medical 
treatment  and  the  comparative  efficiency  of  the  use  of  silver 
wire  and  electricity,  it  is  probably  better  in  favorable  cases  to 
proceed  to  the  latter  at  once,  without  wasting  valuable  time 
upon  the  former.  This  seems  all  the  more  desirable  when  we 
consider  that  wiring  is  not  a  very  dangerous  process,  and  that  it 
is  in  the  early  stages  of  an  aneurism,  when  the  sac  is  still  firm 
and  the  patient  is  in  good  condition,  that  the  best  prospect  of 
cure  exists. 

2.  Soft,  undrawn,  unalloyed  silver  wire,  devoid  of  spring,  wire 
just  as  it  comes  from  the  shop,  is  preferable  to  the  hard,  highly 
drawn  wire,  alloyed  with  copper  and  full  of  spring.  It  is  hardly 
necessary  to  previously  coil  the  wire. 

3.  It  is  still  an  open  question  as  to  which  is  preferable — a 
large  amount  of  wire  or  a  small  amount,  with  the  theoretical 
advantages  in  favor  of  the  former. 

4.  A  strong  electric  current  is  apparently  preferable  to  a  weak 
one. 

5.  The  canula  through  which  the  wire  is  introduced  should 
be  inserted  just  within  the  sac  and  no  further. 

6.  There  is  little  if  any  danger  of  bursting  the  aneurism  from 


TREATMENT    OF    AORTIC    ANEURISMS.  369 

increase  of  pressure  due  to  coagulation  in  a  portion  of  the  sac 
only. 

Cases. — I  shall  make  these  reports  very  brief.  They  will  be  found 
more  in  detail  in  a  paper  by  Dr.  J.  N.  Hall;'  likewise,  many  interest- 
ing points  relating  to  diagnosis,  etc. 

Case  I. — Referred  to  me  by  Dr.  George  E.  Tyler,  of  Denver,  and 
seen  in  consultation  by  Dr.  J.  N.  Hall.  Man,  aged  thirty-six  years. 
Syphilis.  Aneurism  of  innominate  and  arch  of  aorta,  size  of  child's 
fist;  had  existed  for  seven  months.  Bulged  into  neck  to  right  of 
median  line,  and  also  anteriorly,  dislocating  clavicle  and  eroding 
sternum.  Violent  expansile  pulsation.  Very  soft,  especially  at  one 
point.  Pain  in  arm  and  side  of  chest.  Pressure  on  trachea — could 
not  breathe  lying  down.  Pressure  on  recurrent  laryngeal,  with  loss  of 
voice.     Right  pupil  contracted. 

The  patient  was  weak  and  emaciated,  and  altogether  in  a  desperate 
condition.  Dr.  Tyler  had  tried  rest,  diet,  and  potassium  iodide 
without  effect.  Frequent  injections  of  i  per  cent,  and  2  per  cent, 
solutions  of  gelatin  had  proved  utterly  useless.  Hence  it  was  decided 
to  proceed  at  once  to  surgical  measures.  Under  a  local  anaesthetic 
(Schleich's  solution)  the  common  carotid  and  subclavian  were  tied 
at  one  sitting,  the  patient  standing  the  operation  well.  The  effect  of 
this,  although  supplemented  by  gelatin  injections,  was  but  temporary, 
the  pulsations  lessening  in  force  for  a  day  or  two  only.  The  tumor 
then  rapidly  increased  in  size,  dislocating  the  clavicle  more  markedly, 
until  bursting  seemed  imminent — a  matter  of  a  few  days  only.  Wir- 
ing was  then  decided  on,  and  on  September  28,  1900,  eleven  days 
after  the  ligation,  five  or  six  feet  of  No.  27,  undrawn,  unalloyed  silver 
wire  were  introduced.  A  current  of  about  75  ma.  was  passed  for  thirty 
minutes,  the  aneurism  becoming  firmer  and  pulsating  less.  The  cur- 
rent was  turned  on  quite  rapidly,  the  pulse  becoming  weak  and  the 
patient's  condition  alarming  for  a  short  time ;  but  upon  stopping  the 
electricity  and  proceeding  with  more  caution  the  bad  symptoms  quickly 
disappeared.  It  was  thought  at  the  time  that  the  collapse  was  due  to 
a  coil  of  wire  penetrating  the  aorta,  and  a  portion  of  wire  was  with- 
drawn and  again  inserted,  but  this  was  probably  not  the  cause. 

Almost  absolute  rest  was  enjoined  until  January  i,  1901.  During 
this   time   improvement   was   slow   but   continuous.      In    about    five 

'  American  Journal  of  the  Medical  Sciences,  1901,  vol.  ii. 
Am  Surg  84 


370  FREEMAN, 

months  the  tumor,  which  had  long  before  ceased  pulsating  and 
become  solid,  had  almost  disappeared  ;  the  tracheal  shock,  as  pointed 
out  by  Dr.  Hall,  leaving  long  before  the  tracheal  tug. 

At  the  present  time  (April  25,  1901)  no  tumor  is  apparent,  the 
clavicle  is  no  longer  dislocated,  there  is  no  impediment  to  respira- 
tion, no  pain,  and  no  auscultatory  symptoms  whatever,  although  the 
voice,  in  spite  of  great  improvement,  is  still  husky.  The  man  is  at 
work,  without  inconvenience  of  any  kind,  with  a  pick  and  shovel,  on 
the  streets  of  Denver. 

Curiously  enough,  the  patient's  collar  has  worn  an  opening  through 
the  skin  over  the  end  of  the  wire,  and  a  small  sinus  has  been  present 
for  the  past  two  months,  from  which  exudes  a  few  drops  of  pus 
daily. 

Two  attempts  to  show  the  wire  by  means  of  the  Rontgen  rays 
utterly  failed,  an  indefinite  shadow  of  the  contracted  tumor  being 
the  only  result. 

In  the  early  part  of  July,  1901,  the  patient  returned  with  a  portion 
of  wire  presenting  at  the  mouth  of  the  sinus.  I  easily  removed  the 
wire,  which  lay  in  a  small  bunch  within  an  abscess-cavity.  In  a  few 
hours  a  severe  secondary  hemorrhage  (probably  the  result  of  ulcera- 
tion) took  place,  followed  by  other  alarming  hemorrhages  at  intervals 
of  several  days.  The  aneurism  rapidly  re-formed,  causing  compression 
of  the  trachea,  with  coughing  of  some  blood  and  very  difficult  respira- 
tion. Although  the  man  was  in  a  desperate  condition,  another  wiring 
was  done  on  July  13,  1901.  About  fifteen  feet  of  soft,  uncoiled  wire 
(No.  27)  were  inserted,  and  a  current  varying  from  50  to  70  ma. 
turned  on  for  thirty-five  minutes.  The  operation  was  well  borne,  but 
the  dyspnoea  became  progressively  worse,  death  resulting  in  sixty-two 
hours.  Autopsy  revealed  a  firm  and  satisfactory  clot  filling  the  entire 
sacculated  aneurism,  with  the  wire  coiled  throughout  its  substance. 
The  fatal  result  was  due  not  to  hemorrhage,  but  to  pressure  on  the 
trachea,  which  had  not  been  relieved  by  the  operation. 

Case  II. — Man,  aged  fifty-six  years.  Referred  to  me  by  Drs.  Shaw 
and  Collins,  of  Georgetown,  Colorado,  and  Dr.  Roberts,  of  Aguilar. 
Had  been  an  athlete,  continuing  active  exercise  up  to  the  time  at 
which  I  saw  him.  Dr.  J.  N.  Hall  made  a  careful  examination  and 
an  accurate  diagnosis  of  the  size,  situation,  and  general  character- 
istics of  the  tumor.  The  sac  was  attached  to  the  ascending  portion 
of  the  aorta,  just  above  the  valves.  It  presented  in  the  second  inter- 
costal space  to  the  right  of  the  sternum.     There  were  practically  no 


TREATMENT    OF    AORTIC    ANEURISMS.  3/1 

auscultatory  signs,  expansile  pulsation  was  marked,  and  the  tumor 
soft.  Pain  existed  in  the  right  side  of  the  chest  and  ran  down 
the  arm.  It  had  been  noticed  for  perhaps  five  months.  No  other 
pressure  symptoms.  Dr.  Hall,  considering  it  a  favorable  case  for  opera- 
tion, twenty-two  feet  of  undrawn,  unalloyed.  No.  27  silver  wire  were 
introduced  under  local  anaesthesia  on  December  24,  1901.  The 
hemorrhage  was  t'ery  free,  almost  alarming,  the  blood  appearing  when 
the  needle  had  been  introduced  but  a  short  distance.  A  current  of 
75  ma.  was  employed  for  sixty-five  minutes.  Again,  the  current  was 
turned  on  too  rapidly,  producing  a  weak  and  slow  pulse,  and  symptoms 
of  collapse  lasting  a  few  minutes. 

Although  improvement  took  place  in  pain,  expansile  pulsation,  and 
consistency,  the  tumor  continued  to  extend  toward  the  axilla.  An- 
other wiring  was  done  on  February  20,  1901,  some  eight  or  nine  feet 
of  wire  being  used,  the  sitting  lasting  seventy-seven  minutes.  The 
strength  of  current  varied  between  50  ma.  and  80  ma. 

Again,  improvement  was  noted,  but  althoughi  harder  and  without 
appreciable  expansile  pulsation,  the  up-and-down  movement  was  so 
marked  that  another  operation  was  decided  on.  This  was  done  on 
March  13,  1901,  but,  although  the  canula  was  inserted  to  the  hilt, 
about  two  inches,  nothing  but  a  little  serum  was  obtained.  Two  or 
three  feet  of  wire  were  pushed  in  with  difficulty,  and  75  ma.  turned  on 
for  about  seventy  minutes. 

More  solidification  and  contraction  followed,  although  the  heaving 
pulsation  was  still  quite  evident,  as  it  must  be  as  long  as  a  tumor  rest- 
ing on  the  aorta  is  present. 

On  April  29,  1901,  an  exploratory  puncture  was  made,  and  blood 
reached  at  a  depth  of  one  and  a  half  inch,  although  it  did  not 
spurt  through  the  needle  as  on  former  occasions,  but  merely  welled 
out  in  moderate  amount.  Another  wiring  was  done  on  April  30, 
1901,  five  or  six  feet  of  drawn  and  coiled  silver  wire  being  inserted, 
and  a  current  of  75  ma.  turned  on  for  seventy-two  minutes.  Pulsation 
almost  entirely  ceased  at  the  end  of  about  half  an  hour,  and  the 
needle,  which  had  previously  moved  freely  with  each  beat  of  the  heart, 
rested  almost  without  motion,  showing  that  a  satisfactory  clot  had 
been  obtained. 

This  case,  although  not  cured  at  once,  has  shown  continuous 
improvement.  The  vi^all,  which  was  at  first  thin,  has  thickened 
to  one  and  one-half  inch;  the  expansile  pulsation  has  almost 


372  FREEMAN, 

if  not  quite  ceased,  and  the  consistency  has  increased  to  a 
marked  extent.  In  addition,  the  blood,  which  at  first  spurted 
several  feet  through  the  canula,  at  the  last  puncture  did  not 
spurt  at  all,  showing  that  it  existed  as  a  stagnant  pool  in  the 
centre  of  a  firm,  thick  clot.  What  the  outcome  will  finally  be 
it  is  impossible  to  say,  but  the  outlook  seems  encouraging.  A 
letter  received  from  this  patient  on  August  5,  1901,  stated  that 
his  condition  was  satisfactory  in  every  respect. 

To  Dr.  E.  P.  Hershey,  of  Denver,  the  first  to  successfully 
wire  an  aneurism  in  Colorado,  I  desire  to  express  my  indebted- 
ness for  valuable  assistance. 


TREATMENT    OF    AORTIC    ANEURISMS.  373 


DISCUSSION. 

Dr.  J.  M.  T.  Finney,  of  Baltimore. 

My  own  personal  experience  in  the  wiring  of  aneurisms  is  based 
upon  8  cases  in  which  I  have  wired  an  aneurism  of  some  portion  of 
the  aorta.  Four  of  these  cases  were  thoracic  and  4  abdominal  aneu- 
risms. I  have  observed  2  other  cases — i  abdominal  sac,  operated 
upon  by  Dr.  Halsted,  and  i  thoracic  aneurism,  operated  upon  by  Dr. 
Stewart,  of  Philadelphia. 

Of  my  own  cases,  2  were  apparently  cured ;  in  2  the  symptoms 
were  temporarily  relieved  to  a  greater  or  less  extent;  in  2  death  was 
undoubtedly  hastened  by  the  wiring  ;  in  2  others  the  operation  has 
been  too  recent  to  form  any  idea  of  the  ultimate  result,  although  the 
immediate  effect  has  been  satisfactory  in  relieving  pain  and  reducing 
the  size  and  impulse  of  the  sac. 

In  my  experience  the  good  effects  of  the  wiring  have  not  necessarily 
been  immediate,  but  in  the  2  cases  where  the  operation  effected  a 
cure  the  results  were  not  at  once  apparent.  One  of  these  cases,  a 
sea  captain  with  a  large  thoracic  aneurism,  probably  of  the  ascending 
portion,  was  under  observation  for  a  num.ber  of  months;  finally  the 
swelling  and  symptoms  having  practically  disappeared,  and  having 
been  pronounced  probably  well  by  Dr.  Osier,  he  went  to  sea.  After 
some  weeks  he  was  taken  ill,  and  died  a  few  hours  later.  It  was  im- 
possible to  get  any  satisfactory  history  of  his  illness,  so  the  cause  of 
death  must  remain  unknown. 

The  other  case  was  recently  examined  by  Dr.  Osier  over  a  year  after 
the  wiring,  and  was  pronounced  by  him  as  probably  cured,  the  orig- 
inal aneurismal  sac  having  decreased  very  much  in  size,  and  the  im- 
pulse being  very  slight. 

Of  the  two  cases  that  were  temporarily  benefited,  one  a  patient  of 
Dr.  Johnston,  of  Washington,  was  of  enormous  size ;  the  benefit  here 
was  noted  in  the  diminution  of  pulsation  and  relief  of  pain.  The 
aneurism  finally  expanded  in  another  direction  and  later  ruptured. 

The  other  case  was  wired  three  times ;  wiring  was  done  at  different 
places.  He  was  relieved  considerably  after  each  operation,  but  finally 
died  of  exhaustion. 

Of  the  two  fatal  cases,  in  one  the  sac  was  burned  so  badly  by  the 
strength  of  the  electric  current  at  that  point  that  it  afterward  rup- 


374  DISCUSSION. 

tured.  The  other  case,  an  abdominal  aneurism  high  up,  had  been 
apparently  considerably  relieved  by  the  wiring,  when  suddenly,  about 
a  week  following  the  operation,  the  patient  died  with  symptoms  sug- 
gesting pulmonary  embolism  or  possibly  rupture  of  the  sac.  We  were 
unable  to  obtain  an  autopsy. 

Of  the  other  two  cases,  one  abdominal  and  the  other  thoracic,  it  is 
too  early  to  speak,  although  they  both  report  themselves  as  feeling 
better  than  before  the  operation,  and  there  has  apparently  been  some 
decrease  in  size  and  amount  of  pulsation. 

As  to  the  technique  of  the  operation,  we  have  followed  that  described 
by  Dr.  Hunner  in  a  recent  paper,  published  in  the  Johns  Hopkins 
Bulletin.  We  should  advise  the  use  of  cocaine  where  practicable  ; 
we  were  able  to  use  it  in  two  of  our  abdominal  cases.  Of  course,  a 
general  anaesthetic  is  not  necessary  in  thoracic  cases.  The  method  of 
preparation  and  sterilization  of  the  wire,  needle,  etc.,  was  then  shown, 
and  a  demonstration  given  of  the  technique  of  the  operation. 

Dr.  De  Forest  Willard,  of  Philadelphia. 

I  have  I  case  (which  is  still  under  treatment)  of  an  enormous  trau- 
matic thoracic  aneurism  which  fills  the  entire  right  thorax.  Four 
months  ago  I  introduced  silver  wire  and  applied  electricity.  The 
relief  from  the  pain  has  been  so  great  that,  even  if  these  cases  do  not 
recover,  it  seems  to  me  that  it  is  advisable  to  institute  this  form  of 
treatment.  It  was  very  gratifying  to  find  such  improvement  in  the 
man,  and  he  was  made  perfectly  comfortable.  He  is  a  man  whom 
one  cannot  control,  and  in  spite  of  his  aneurism  will  use  unnecessary 
muscular  exertion.  The  improvement  has  been  exceedingly  great, 
but  there  is  now  an  extension  of  the  sac  toward  the  right  axilla.  I 
hope  to  induce  him  to  submit  to  a  second  operation,  which  will  un- 
doubtedly prolong  his  life  for  several  months,  although  I  hardly  believe 
it  possible  to  secure  a  perfect  cure. 

A  moderate  quantity  of  wire  is  desirable,  and  I  am  in  favor  of  fill- 
ing the  sac  quite  thoroughly,  so  as  to  make  many  points  of  clot.  A 
moderate  current  is  also  advisable,  since  an  excessive  current  may  do 
harm,  and  we  simply  want  sufficient  to  cause  a  coagulation  around 
the  coils  of  wire — i.e.,  about  lo  to  20  milliamperes. 

Dr.   R.   Matas,  of  New  Orleans. 

Dr.  Freeman's  results  are  admirable,  and  I  congratulate  him.  I 
regret  that  my  experience  has  not  been  so  fortunate.      I  have  recently 


TREATMENT    OF    AORTIC    ANEURISMS.  375 

reported  two  cases,  one  of  which  was  operated  by  my  colleague,  Dr, 
Parham,  in  1896,  in  which  death  followed  after  a  survival  of  forty-five 
days,  from  the  migration  of  the  wire  into  the  aorta  and  the  heart,  and 
my  patient's  case  in  which  death  followed  nineteen  days  after  wiring 
and  electrolysis,  from  secondary  rupture  of  the  sac,  caused  by  defective 
conditions  inherent  to  the  method  itself.  These  cases,  with  a  critical 
analysis  of  others  reported  in  the  literature,  will  appear  in  the  Trans- 
actions of  the  Southern  Surgical  and  Gynecological  Association  for 
1900.  While  my  study  of  the  method  in  its  relations  to  abdominal 
aneurism  has  led  me  to  look  upon  it  unfavorably,  as  a  whole,  I  recognize 
that  the  conditions  in  the  thorax  are  different,  and  that  it  is  of  some 
value  is  well  shown  by  Dr.  Freeman's  interesting  cases. 

In  view  of  the  great  attention  given  to  the  technique  of  the  Moore- 
Corradi  procedure,  its  applications  deserve  more  than  passing  notice. 
The  indications  and  limitations  of  this  method  have  not  been  studied 
sufficiently.  In  our  anxiety  to  perfect  the  technique  we  have  over- 
looked the  anatomical  conditions  which  contraindicated  its  applica- 
tion. Undoubtedly  great  improvements  have  been  made  in  the 
technique,  but  these  are  of  little  help  to  the  patient  when  we  consider 
that  the  cure  of  the  aneurism  by  this  or  any  other  coagulating 
method  may  lead,  ipso  facto,  to  the  death  of  the  patient  by  obliterating 
the  orifice  of  important  visceral  branches;  and  what  is  worse,  that  this 
unfortunate  result  is  most  likely  to  follow  after  wiring  the  aneurisms  of 
the  upper  or  cceliac  division  of  the  abdominal  aorta,  /.  e.,  in  about  50 
per  cent,  of  the  cases  !  Other  grave  objections  could  be  presented, 
but  this  one  alone  is  sufficient  to  make  us  pause  before  resorting  to  so 
dangerous  a  procedure. 

Dr.  Freeman.  Whether  the  formation  of  a  clot  in  a  portion  of  an 
aneurism  will  result  in  increase  of  tension  in  the  remainder,  and  rup- 
ture, is  open  to  doubt.  The  general  arterial  tension  is  certainly  not 
increased  ;  it  is  rather  decreased,  owing  to  hemorrhage,  which  nearly 
always  takes  place  during  the  operation.  An  aneurism  represents  a 
more  or  less  separate  pool  of  blood  lying  beside  the  aorta,  and  when 
a  wave  from  the  heart  strikes  this  pool  expansion  takes  place  which  is 
equal  in  all  directions.  The  force  of  this  expansion  would  not  be 
increased  by  the  formation  of  a  clot  in  a  portion  of  the  sac.  This  can 
be  illustrated,  as  I  have  stated  in  my  paper,  by  means  of  a  rubber 
glove  filled  with  water  under  a  given  pressure,  into  which  is  intro- 
duced some  substance  to  represent  a  clot.     It  will  be  found  that  the 


376  TREATMENT    OF    AORTIC    ANEURISMS. 

pressure,  measured  by  a  stream  of  water  forced  through  a  hole  in  the 
glove,  is  not  increased.  The  ruptures  which  have  followed  wiring 
have  not  been  due,  in  my  opinion,  to  increased  pressure,  but  to  the 
fact  that  the  aneurism  has  been  just  on  the  point  of  rupture,  and  the 
operations  have  failed  to  check  this  unfortunate  outcome. 

The  remarks  of  Dr.  Matas  refer,  of  course,  to  the  abdominal  aorta 
alone,  and  here  they  possess  some  foundation,  although  cures  have 
resulted.  As  regards  the  thoracic  aorta,  however,  the  case  is  entirely  dif- 
ferent. Here  the  operation  does  not  seem  to  be  very  dangerous,  and 
the  results  have  been  better  than  those  obtained  by  any  other  method. 


DOUBLE  RENAL  CALCULUS. 


By  S.  J.  MIXTER,  M.D., 

BOSTON,   MASS. 


L.  N.,  machinist,  aged  twenty-seven  years,  entered  the  Massachu- 
setts General  Hospital  on  August  23,  1900.  When  between  seventeen 
and  twenty-five  years  old  he  had  several  attacks  of  renal  colic  on  each 
side,  followed  by  the  passage  of  small  stones  twice  the  size  of  head  of 
pin.     During  these  years  often  passed  gravel  "size  of  iron  filings." 

Now,  when  walking  or  working,  has  a  dull  aching  pain  just  under 
ribs  on  right  side,  the  pain  sometimes  extending  around  to  back. 
Urine  is  at  times  "  as  red  as  blood,"  and  sometimes  contains  gravel. 
He  is  a  well-developed  and  nourished  man,  and  has  worked  at  his  trade 
up  to  time  of  entrance  to  the  hospital.  Kidneys  cannot  be  felt,  and 
there  is  little  if  any  tenderness  in  renal  regions. 

Urine.  Slightly  acid,  1012  ;  slight  trace  of  albumin.  Rare  hya- 
line cast ;  frequent  small  and  large  round  cells  ;  rare  squamous  cells  ; 
many  leucocytes;  a  few  fresh  blood  corpuscles;  very  many  triple 
phosphate  crystals. 

An  X-ray  showed  large  shadows  in  region  of  each  kidney,  so  large 
that  it  was  thought  to  be  accidental,  but  four  other  plates  showing  the 
same  thing,  there  remained  no  doubt  as  to  the  presence  of  stones  in 
both  kidneys. 

On  September  5th  the  left  kidney  was  operated  on,  the  usual  in- 
cision showing  a  healthy  looking  and  but  slightly  enlarged  kidney,  in 
which  could  easily  be  felt  a  large  irregular  stone.  The  kidney  was 
split  on  its  posterior  border  nearly  its  whole  length,  and  the  stone  was 
removed  in  two  parts.  There  were  originally  two  stones,  as  shown  by 
the  faceting,  but  they  were  cemented  together  by  a  thin  layer  that 
covered  them  both.     The  whole  mass  weighed  1020  grains. 

During  the  operation  hemorrhage  was  quite  profuse  from  the  kidney, 
and  was  easily  controlled  by  gauze  packing. 


378  MIXTER, 

Recovery  was  uneventful.  All  packing  was  removed  by  the  sixth 
day,  and  urine  entirely  ceased  flowing  from  the  wound  in  eighteen 
days. 

On  February  ii,  1901,  he  again  entered  the  hospital  for  operation 
on  the  other  kidney.  An  X-ray  showed  no  sign  of  stone  on  left  side, 
but  a  fairly  large  one  on  right.  The  operation  was  on  February  14th. 
The  kidney  was  found  to  be  almost  normal  in  appearance,  the  pelvis 
being  somewhat  dilated.  Two  perfectly  smooth  round  stones  were 
removed,  weighing  220  and  20  grains. 

Urine  escaped  from  the  wound  for  about  two  weeks,  and  the  patient 
left  the  hospital  two  weeks  later. 

This  case  is  especially  interesting  as  showing  how  large  a  mass  of 
stone  maybe  present  in  the  kidney  without  seriously  affecting  its  struc- 
ture or  functions.  Suppurating  kidneys,  containing  large  masses  of 
stone  are  not  uncommon,  but  the  whole  organ  is  generally  converted 
into  a  sacculated  bag,  full  of  pus,  and  the  renal  tissue  is  seriously 
degenerated.  Such  cases  almost  always  demand  removal  of  the  organ, 
or  a  permanent  suppurating  fistula  follows  incision. 

Skiagraphs  were  most  useful  in  this  case  as  showing  the  relative  size 
of  the  stones  and  their  presence  in  both  kidneys. 


DOUBLE  RENAL  CALCULUS.  3/9 


DISCUSSION. 


Dr.  J.  M.  T.  Finney,  of  Baltimore. 

I  have  recently  operated  upon  a  very  interesting  case  of  stone  in 
both  kidneys.  A  positive  diagnosis  of  stone  was  made  in  the  right 
kidney,  and  it  was  thought  probable  that  a  small  one  existed  also  in 
the  left,  although  this  could  not  be  definitely  determined. 

I  had  seen  the  patient  two  years  previously ;  he  then  gave  symp- 
toms suggesting  stone  in  the  right  kidney.  I  advised  an  exploratory 
incision,  but  it  was  declined.  He  again  entered  the  Johns  Hopkins 
Hospital  a  few  weeks  ago,  saying  that  after  a  severe  attack  of  grippe 
his  trouble  referred  to  in  the  right  kidney  had  much  increased.  Exam- 
ination of  the  urine  showed  nothing  definite  but  a  large  amount  of 
pus. 

Dr.  Young  kindly  catheterized  the  ureters  and  secured  a  clear  speci- 
men from  the  left  kidney,  while  that  from  the'  right  contained  a  large 
amount  of  pus. 

Dr.  Brown  kindly  took  a  number  of  skiagraphs  and  demonstrated 
the  presence  of  a  large  stone  in  the  right  kidney,  for  some  reason  or 
other  the  skiagraph  of  the  left  kidney  was  negative.  Upon  the 
strength  of  these  examinations  I  advised  and  performed  a  nephrot- 
omy of  the  right  kidney,  and  removed  a  large  branching  stone.  The 
kidney  itself  was  much  disorganized.  There  was  complete  suppres- 
sion following  the  operation,  and  the  patient  died  on  the  fourth  day 
of  uraemia. 

The  autopsy  revealed  a  very  interesting  condition  ;  the  left  kidney 
showed  a  double  pelvis  and  ureter  for  about  six  inches  down.  A 
large  branching  stone  filled  the  lower  pelvis.  A  small  portion  of  this 
stone  had  broken  off  and  plugged  completely  the  orifice  of  that  branch 
of  the  ureter  just  above  the  bifurcation.  This  lower  half  of  the  kid- 
ney was  little  more  than  an  abscess  cavity.  The  upper  half  of  the 
kidney  was  comparatively  normal.  The  explanation  then  of  the 
results  of  Dr.  Young's  catheterization  was  that  the  catheter  had  col- 
lected the  urine  only  from  the  upper  portion  of  the  left  kidney,  which 
was  practically  the  only  good  kidney  substance  that  the  patient  had, 
the  lower  portion  of  that  kidney  and  the  whole  of  the  right  kidney 
being  very  much  disorganized. 

This  case  simply  illustrates  how  even  the  most  thoroughly  scientific 
methods  of  diagnosis  may  be  at  times  misleading. 


A  NEW  METHOD  OF  CLOSING  THE  WOUND  IN 
THOROUGH  REMOVAL  OF  THE  BREAST. 


By  S.  J.  MIXTER,  M.D., 

BOSTON,  MASS. 


Operations  for  the  removal  of  malignant  tumors  of  the  breast 
should  be  done  for  two  purposes  :  first,  to  endeavor  to  secure  a 
radical  cure  in  cases  not  too  far  advanced  ;  and,  second,  to 
remove  a  sloughing  or  painful  mass  where  a  cure  cannot  be 
expected.  It  is  in  the  first  class  of  cases  that  the  surgeon 
should  do  the  most  thorough  operation  possible,  and  as  a  gen- 
eral rule  the  smaller  the  malignant  mass  the  greater  should  be 
the  sacrifice  of  the  surrounding  tissues. 

Thorough  local  removal  I  believe  to  be  fully  as  important  as 
a  thorough  dissection  of  the  axilla  and  often  the  subclavian 
region,  the  skin,  breast  and  pectoral  muscles  being  removed  in 
one  mass,  the  clavicular  fibres  of  the  pectoralis  major  being  left, 
unless  the  disease  is  in  the  upper  part  of  the  breast. 

The  skin  incision  should  begin  well  above  the  anterior  fold 
of  the  axilla,  so  that  after  the  removal  of  the  pectoralis  the  scar 
will  still  be  in  front  of  and  not  across  the  axilla.  From  here 
sweeping  around  the  breast  to  the  middle  line,  everything  is 
removed  to  the  ribs  and  intercostals. 

Such  an  incision  leaves  a  large  defect  to  be  closed,  and  even 
in  patients  whose  skin  slides  fairly  well,  there  would  be  an  un- 
covered space  larger  than  the  hand  should  an  attempt  be  made 
to  suture  without  some  form  of  plastic  operation.  Skin-graft- 
ing, either  at  the  time  of  the  operation  or  later,  will  cover 
the  ribs,  it  is  true,  but  the  resulting  scar  is  thin  and  very 
uncomfortable. 


THOROUGH     REMOVAL    OF    THE    BREAST.  38I 

In  more  than  20  suitable  cases  I  have  lately  closed  this  defect 
by  sliding  or  transplanting  the  opposite  breast,  so  that  the  nip- 
ple comes  at  the  median  line. 

An  incision  is  made  from  the  lower  and  inner  median  angle 
of  the  original  incision,  carried  directly  across  beneath  the 
sound  breast,  and  then  curved  upward  to  the  posterior  fold  of 
the  axilla.  The  breast  and  surrounding  skin  are  then  dissected 
from  the  underlying  fascia,  care  being  taken  not  to  divide  the 
branches  that  run  to  it  directly  from  the  axilla  or  those  that 
are  about  the  outer  part  of  the  clavicle.  The  skin  should  be 
thoroughly  separated  from  the  deep  tissues  over  the  attachment 
of  the  sternomastoid. 

If  now  the  knife  be  carried  under  the  skin  and  subcutaneous 
tissues  below  the  lower  border  of  the  incision,  exposing  the  upper 
part  of  the  abdominal  fascia,  it  will  be  found  that  the  defect  can 
be  easily  closed  without  undue  tension.  In  some  cases  a  short 
vertical  incision  just  below  the  middle  of  the  sound  breast  and 
extending  to  its  border  gives  additional  length  to  the  flap. 

In  no  case  have  I  had  the  slightest  trouble  with  the  flap. 
There  has  always  been  primary  union,  and  no  sloughing  has 
followed  the  extensive  dissection.  The  nipple  that  at  the  time 
of  the  operation  is  in  the  median  line  draws  over  somewhat 
toward  its  natural  situation  owing  to  the  flattening  of  the  breast. 
I  may  add  that  no  patient  has  complained  of  the  slight  de- 
formity resulting. 


382  THOROUGH     REMOVAL    OF    THE    BREAST, 


DISCUSSION. 

Dr.  J.  Collins  Warren,  of  Boston. 

The  question  of  what  to  do  after  removal  of  the  breast  is  an  im- 
portant one,  as  very  often  patients  are  sensitive  to  the  deformity.  The 
aesthetic  side  of  the  operation  must  be  taken  into  the  account,  and  it 
is  with  this  idea  in  view  that  I  have  tried  to  devise  a  plan  of  closing  the 
wound.  If  we  could  get  a  linear  scar  it  would  be  the  best  thing  to  do. 
The  operation  as  performed  by  Dr.  Mixter  seems  to  work  smoothly ; 
there  is  no  tension,  and  the  wound  heals  quickly,  but  it  alters  the 
woman's  shape  and  makes  her  appear  pigeon-breasted.  The  outlines 
of  the  body  are  something  that  a  woman  prizes  highly  in  making  her 
toilet.  By  taking  a  flap  from  the  side  the  wound  can  be  closed  with- 
out additional  deformity. 

Dr.  W.  H.  Carmalt,  of  New  Haven,  Conn. 

I  had  a  case  of  recurrent  carcinoma  of  the  breast  to  operate  upon, 
in  which  the  defect  left  after  the  removal  of  the  growth  was  too  large 
to  be  filled  up  by  any  ordinary  sliding  operation  from  the  immediate 
neighborhood  ;  and,  as  I  object  most  decidedly  to  let  this  class  of  cases 
heal  by  granulation,  I  employed  a  procedure  similar  to  that  described 
by  Dr.  Mixter  of  transplanting  the  other  breast  to  assist  in  covering 
in  the  defect  with  a  good  result.  I  cannot  from  memory  (this  was 
several  years  ago)  describe  the  incisions — one  "cuts  his  coat  accord- 
ing to  the  cloth"  in  plastic  surgery — but  the  wound  healed  by  first 
intention,  and  the  woman  expressed  herself  afterward  as  entirely  satis- 
fied with  the  result. 


RESECTION   OF   A    LARGE    PART   OF    THE    CHEST 
WALL     FOR     A     SARCOMA;     USE     OF     FELL'S 
APPARATUS     FOR     ARTIFICIAL     RESPIRA- 
TION; LATE   CONTINUOUS   FEVER  DUE 
TO    STAPHYLOCOCCUS    BLOOD    IN- 
FECTION; SUCCESSFUL  USE  OF 
THE   ANTISTREPTOCOCCIC 
SERUM;    COMPLETE 
RECOVERY. 


By  W.  W.  keen,  M.D.,  LL.D.,  F.R.C.S.  (Hon.), 

PHILADELPHIA. 


L.  H.  (colored),  a  woman,  aged  twenty-five  years,  was  admitted  to 
the  Jefferson  Medical  College  Hospital,  October  7,  1900.  Her  father, 
mother,  and  five  brothers  and  sisters  are  living  and  well ;  one  brother 
has  a  growth  the  size  of  a  walnut  under  the  angle  of  the  jaw ;  two 
brothers  died  of  dysentery  ;  one  aunt  with  a  tumor,  at  the  age  of 
forty,  and  another  is  very  ill  with  an  abdominal  tumor.  There  is  no 
tubercular  family  history.  She  had  the  ordinary  diseases  of  childhood 
when  quite  young.  She  first  began  to  menstruate  at  sixteen.  There 
is  no  history  of  specific  infection. 

On  December  24,  1898,  she  was  thrown  out  of  a  wagon,  and  injured 
her  right  side,  but  not  so  severely  as  to  prevent  her  continuing  her 
housework.  In  March,  1900,  she  first  noticed  a  small  growth  about 
the  size  of  an  egg  at  the  lower  angle  of  the  right  scapula.  This  growth 
has  gradually  increased  in  size,  and  has  been  the  seat  of  a  dull,  aching, 
almost  constant  pain,  excepting  at  irregular  short  intervals,  when  it 
becomes  very  intense  and  radiates  as  far  as  the  median  line  anteriorly. 
At  present  deep  respiration  causes  pain. 

On  admission  there  was  found  to  be  a  tumor  in  the  right  postero- 
lateral aspect  of  the  chest,  extending  from  the  edge  of  the  erector 
spinse  mass  to  the  outer  border  of  the  right  breast,  and  from  the  fifth 


384 


KEEN, 


to  the  eleventh  ribs  inclusive.  It  measured  15  cm.  vertically,  26  cm. 
horizontally,  and  was  elevated  about  7.5  cm.  above  the  general  level 
of  the  chest.  There  was  no  infection  of  the  overlying  skin,  nor  was 
this  adherent.  The  tumor  itself  was  fixed,  only  slightly  lobulated, 
and  was  not  tender.  Her  appetite  was  good,  bowels  regular,  tongue 
slightly  coated,  heart  and  lungs  normal. 

The  blood-count  on  October  i6th  was  as  follows:  Erythrocytes, 
4,100,000;  leucocytes,  7000;  haemoglobin,  60  per  cent.;  polymor- 
phonuclear neutrophiles,  65  per  cent.;  small  lymphocytes,  22,5  per 
cent.  ;  large  lymphocytes,  10  per  cent.  ;  eosinophiles,  25  per  cent. 

Fig.  I. 


Tumor  before  operation. 


Urine :  Specific  gravity,  1026  ;  acid  ;  no  albumin  or  sugar  ;  urea, 
1.9  per  cent.  By  the  microscope,  amorphous  urates,  a  few  squamous 
epithelial  cells ;  no  crystals,  pus,  blood,  or  tube  casts. 

My  diagnosis  was  a  sarcoma  involving  the  chest  wall,  but  presum- 
ably only  beginning  to  invade  the  cavity  of  the  chest  without  any 
evidences  of  adhesions  of  the  lung.  The  same  conclusion  was  reached 
by  Prof.  James  C.  Wilson,  who  kindly  examined  her  chest  for  me  with 
great  care.  In  view  of  the  facts  set  forth  in  Dr.  F.  W.  Parham's 
"  Thoracic  Resection  for  Tumors  Growing  from  the  Bony  Wall  of  the 


RESECTION    OF    THE    CHEST    WALL    FOR    A    SARCOMA.       385 

Chest,"  I  decided  to  use  Fell's  apparatus  for  artificial  respiration  at 
the  time  of  the  operation. 

Operation,  October  17,  1900,  in  the  Jefferson  Medical  Hospital 
clinic.  I  made  a  large  horseshoe-shaped,  flap  by  an  incision  begin- 
ning at  the  outer  border  of  the  right  breast,  extending  downward  to 
the  eleventh  nb,  and  sweeping  backward  and  upward  quite  near  the 
vertebral  spinous  processes  as  far  as  the  level  of  the  inferior  angle  of 
the  scapula.  This  flap,  consisting  only  of  skin  and  the  muscles  over- 
lying the  tumor,  was  then  reflected  upward.  In  doing  this  I  was 
extremely  careful  not  to  include  any  of  the  tumor  in  the  flap.    I  then 


Fig.  2. 


Tumor  before  operation. 


was  able  to  introduce  my  hand  under  tlie  lower  border  of  the  tumor, 
and  found  that,  like  a  mushroom,  it  had  a  base  considerably  smaller 
than  the  body  of  the  tumor.  Accordingly,  in  order  to  remove  as 
little  of  the  chest  wall  as  was  possible,  I  gradually  tore  the  tumor 
loose  from  the  ribs  and  peeled  it  off"  entirely.  A  second  advantage, 
beside  the  smaller  amount  of  chest  wall  resected,  was  that  I  was  able 
to  divide  the  diseased  ribs  anteriorly  and  posteriorly  at  selected  points 
at  a  sufificient  distance  away  from  the  disease  before  opening  the 
pleural  cavity,  which  last  would  probably  involve  the  collapse  of  the 
lung.  A  third  advantage  was,  that,  having  divided  the  bones,  I  would 
be  able  to  divide  the  soft  parts  very  rapidly,  and  so  diminish  the 

Am  Surg  25 


386  KEEN, 

period  during  which  collapse  of  the  lung,  especially  the  initial  col- 
lapse, would  be  a  threatening  danger. 

I  found  that  the  fifth,  sixth,  seventh,  and  eighth  ribs,  and  the  tissues 
between  them,  were  all  diseased,  but  the  ninth,  tenth,  and  eleventh 
were  free.  I  first  separated  the  pleura  from  the  anterior  surface  of  the 
ribs  by  a  periosteal  separator,  and  by  means  of  bone  forceps  divided 
each  of  these  four  ribs  anteriorly  and  posteriorly  without  invading  the 
pleural  cavity.  Then,  with  a  pair  of  scissors,  I  rapidly  divided  the 
soft  parts,  including  the  pleura,  and  in  a  moment  had  removed  the 
entire  tumor,  and  made  an  aperture  in  the  chest  wall  measuring  verti- 
cally 18  cm.  and  horizontally  12  cm.  I  found  that  the  tumor  was 
just  bulging  the  pleura  inward,  but  had  not  yet  contracted  any  adhe- 

FlG.  3. 


Tumor  removed,  one-fourlh  natural  size. 

sions  with  the  lung,  but  soon  would  have  done  so.  As  soon  as  I 
opened  the  pleural  cavity  the  lung  collapsed.  Fell's  apparatus  for 
artificial  respiration  was  immediately  put  in  use  by  Dr.  Spencer.  It 
was  used  by  means  of  a  face  mask  which  covered  the  mouth  and 
nose,  but  was  not  air-tight.  For  this  reason  it  did  not  work 
satisfactorily,  and  the  collapsed  lung  was  only  very  slightly  filled 
with-  air.  But,  fortunately,  the  patient  suffered  very  little  indeed 
from  the  practically  almost  total  and  immediate  exclusion  of  the  right 
lung  from  any  part  in  respiration.  While  I  was  doing  the  earlier  part 
of  the  operation,  one  of  my  assistants  had  laid  bare  a  vein  at  the  bend 
of  the  elbow  in  the  opposite  arm,  but  without  opening  the  vein,  so 
that  he  was  ready  at  an  instant's  notice  to  proceed  to  transfusion  had 


RESECTION    OF    THE    CHEST    WALL    FOR    A    SARCOMA.       387 

it  been  necessary.  As  at  no  time  during  the  operation  did  the  neces- 
sity arise,  the  wound  was  closed  at  the  end  of  the  operation,  and  gave 
no  further  trouble. 

As  soon  as  I  had  made  the  large  opening  in  the  chest  wall,  I  seized 
the  lung  with  my  hand,  drew  it  up  to  the  opening,  and  as  rapidly  as 
possible,  with  a  long,  continuous  catgut  suture,  sutured  the  lung  to  the 
edge  of  the  opening  throughout  its  entire  circumference.  In  doing 
so  I  passed  a  curved  Hagedorn  needle  directly  through  the  lung  tissue, 
puncturing  it  perhaps  to  the  depth  of  2  to  3  cm.  As  the  traction 
on  the  upper  and  lower  portions  separated  the  two  lobes,  I  sutured 
these  two  lobes  together  at  two  points,  the  object  of  one  of  these  sutur- 
ings  being  to  diminish  the  resulting  space  for  a  pneumothorax.  The 
flap  was  then  placed  in  position,  sutured  at  close  intervals,  and  the 
wound  sealed  with  iodoform  collodion  throughout.  At  the  end  of 
the  operation  the  patient  was  in  a  very  good  condition. 

The  following  observations  were  made  by  Dr.  J.  W.  Macintosh,  who 
had  charge  of  the  anaesthetic. 

1.30  p  M.   Operation  begun. 

2.10.  Pleural  cavity  opened ;  respiration,  26;  pulse,  118. 

2.15.   Respiration,  24;   pulse,  120. 

2.20.   Respiration,  30;   pulse,  no. 

2.25.  Anaesthetic  stopped. 

In  spite  of  the  character  and  length  of  the  operation,  the  tempera- 
ture fell  only  to  97.2°  after  the  operation.  On  the  second  day  it  rose 
to  100.6,  and  from  the  fourth  day  (October  21st)  to  the  sixteenth 
day  (November  7th)  fluctuated  between  100°  and  102°.  Neither 
myself  nor  my  house  surgeon.  Dr.  Swartz,  nor  Professors  J.  C.  Wilson, 
W.  Joseph  Hearn,  or  J.  Chalmers  Da  Costa,  all  of  whom,  at  my  re- 
quest, examined  the  patient,  could  find  any  post-operative  evidence 
either  of  a  pneumothorax  or  a  pyothorax.  Very  little  traumatic 
pleurisy  and  no  recognizable  effusion  followed  the  operation,  though 
the  patient  suffered  moderately  from  pain  at  the  site  of  the  operation. 
This  was  very  gratifying,  especially  in  view  of  the  suturing  of  the 
lung  to  the  edge  of  the  opening. 

Not  being  able  to  find  any  local  reason  for  the  continued  high 
temperature,  I  asked  Dr.  F.  J.  Kalteyer  to  examine  the  blood.  This 
was  done  on  November  7th,  the  blood  being  drawn  by  Sittmann's 
method.     The  result  was  as  follows  : 

"Erythrocytes,  3,425,000  per  cubic  millimetre;  leucocytes,  18,000 
per  cubic  millimetre  ;  haemoglobin,  34  per  cent.  ;  color  index,  0.5, 


388 


KEEN, 


"Differential  count  of  the  leucocytes:  Polymorphonuclear  neu- 
trophiles,  95  per  cent.  ;  small  leucocytes,  2  per  cent. ;  large  lympho- 
cytes, 3  per  cent.  ;  eosinophiles,  o. 

"  Plates  were  made  and  tubes  inoculated.  One  plate  at  the  end  of 
forty- eight  hours  showed  five  colonies.  Three  of  these  were  whitish 
in  color  and  slightly  granular  in  appearance  and  circular  in  outline. 
Spreads  were  made  and  stained  with  Loefifler's  methylene-blue  and  by 
Gram's  method.  The  growths  were  found  to  be  staphylococcus  pyo- 
genes albus  in  pure  culture.  The  remaining  two  colonies  consisted 
of  pure  cultures  of  the  baccillus  subtilis,  a  probable  contaminating 
organism.     The  other  plate  remained  sterile  after  seven  days." 


Fk; 


Appearance  after  operation. 


The  use  of  the  antistreptococcic  serum  (Parke,  Davis  &  Co.),  in 
doses  of  ID  c.cm.,  was  begun  and  continued  once  daily  from  Novem- 
ber 9th  to  14th  inclusive,  six  injections  in  all  being  given.  The  tem- 
perature immediately  began  to  fail,  and  dropped  progressively  till  it 
reached  the  normal  on  the  14th,  when  the  injections  were  discon- 
tinued. After  that  there  was  no  rise  above  99°.  On  the  15th,  and 
again  on  the  27th,  the  blood  was  re-examined,  and  was  proved  to  be 
sterile  in  each  instance.  Shortly  after  this  she  went  home  well.  Fig.  4 
shows  the  final  result. 

Professor  Coplin  made  the  following  pathological  report  on  the 
specimen  : 


I 


RESECTION    OF    THE    CHEST    WALL    FOR    A    SARCOMA.       389 

"The  specimen  consists  of  a  semi-ovoidal  mass  of  tissue,  18  cm. 
long,  12  cm.  wide,  and  6  cm.  thick;  weight,  625  grammes. 

"On  the  convex  surface  is  a  triangular  area  of  muscular  tissue,  2 
cm.  thick  on  one  edge,  tapering  to  a  tendinous  insertion  on  the 
opposite  side.  The  course  of  the  fibres  correspond  in  general  to  the 
long  axis  of  the  tumor.  The  muscular  mass  is  rather  firmly  attached 
to  the  tumor  beneath.  A  second  piece  of  muscle,  i  cm.  thick,  2  cm. 
wide,  and  10  cm.  long,  runs  from  one  edge  diagonally  across  the 
tumor  and  terminates  near  the  insertion  of  the  previously  described 
muscle.  A  delicate  layer  of  connective  tissue  attaches  the  muscle  to 
the  tumor  and  extends  over  the  uncovered  parts  of  the  tumor. 

"The  inferior  surface  is  oval  in  outline,  and  presents  muscle  fibre 
generally  scattered  over  the  surface.  Three,  distinct  elevations,  0.5 
cm.  high  and  0.5  cm.  long,  are  demonstrable  upon  this  surface. 
Finally,  sections  of  four  ribs,  three  11.5  cm.  long,  one  6  cm.  long, 
are  attached.  Interstitial  muscular  structure  holds  these  fragments 
firmly  together.  On  the  inner  aspect  of  the  tib  sections,  and  par- 
tially covering  the  middle  two,  is  a  pale  yellow  elevation  of  tissue, 
4  cm.  long,  2  cm.  wide,  i  cm.  thick.  This  tissue  is  rather  firm, 
slightly  nodular,  and  has  attached  to  its  upper  margin,  extending 
from  the  middle  of  the  mass  to  3  cm.  beyond  it,  a  ribbon  of  appar- 
ently the  same  tissue  as  the  nodule.  A  similar  ribbon  extends  along 
the  lower  edge  3  cm.  beyond  the  nodule  to  either  side.  This  nodule 
is  a  projection  of  the  tumor  between  the  ribs  (toward  the  pleura), 
and,  in  common  with  the  remainder  of  the  concave  aspect  of  the 
surface,  is  covered  by  what  appears  to  be  a  serous  membrane.  In 
order  to  avoid  mutilation  of  the  specimen  the  ribs  were  not  sectioned, 
but  no  gross  evidence  of  infiltration  by  the  tumor  is  to  be  recognized. 

"Specimens  were  fixed  in  Heidenhain's  solution  and  stained  with 
haematoxylin  and  picric  acid,  toluidin-blue,  and  by  other  combina- 
tions. 

"The  tissue  is  composed  largely  of  spindle-cell  elements,  which 
cells  are  arranged  in  a  highly  interwoven  texture.  These  cells  have 
interspersed  among  them  elements  of  multipolar  outline  tending 
strongly  in  appearance  to  myxomatous  cells.  The  bodies  described 
are  in  a  matrix  of  fibrous  formation  resembling  that  observed  in 
fibromata. 

"  Mast  cells  are  to  be  observed  with  varying  frequency,  but  on  the 
whole  are  not  very  numerous. 

"  Sections  from  the  intercostal  and  subparietal  pleural  growth  show  a 


390  KEEN, 

much  closer  aggregation  of  the  types  of  cells  described,  in  addition  to  a 
large  number  of  round  cells  possessing  the  same  morphology  and  tinc- 
torial reactions  of  lymphoid  cells  situated  immediately  beneath  the 
pleura.  The  lymphoid  cells  are  particularly  numerous  at  either  end 
where  the  growth  terminates  in  the  ridges  described  in  the  gross 
specimen.  These  ridges  are  of  adipose  tissue  somewhat  infiltrated  by 
lymphoid  cells.  The  pleura  has  lost  its  characteristic  histological 
structure,  becoming  somewhat  fibrous.  Mast  cells  are  present,  but 
less  numerous  than  in  the  other  sections  of  the  tumor. 

"The  bloodvessels  are  numerous  and  highly  atypic,  being  simply 
channels  lined  by  the  spindle  cells  before  described.  Around  a  few 
of  the  bloodvessels  a  lymphoid  cell  infiltration  is  observed. 

"  Diagnosis. — Spindle-cell  sarcoma.  The  cellular  elements  are  for 
the  most  part  of  the  so-called  small-fpindle  type,  but  large  spindle 
cells  and  numbers  of  multipolar  cells  are  also  present.  No  satisfac- 
tory explanation  for  the  presence  of  elements  morphologically  identi- 
cal with  lymphoid  cells  can  be  given.  Their  possibly  inflammatory 
origin  cannot  be  excluded." 

Remarks.  There  are  a  few  points  to  which  I  would  call 
special  attention  : 

1.  The  method  of  separating  the  tumor  from  the  chest  wall 
so  as  to  determine  more  exactly  the  limits  of  the  disease  and 
lessen  the  size  of  the  opening  to  be  made  in  the  chest. 

2.  The  division  of  the  ribs  anteriorly  and  posteriorly  prior  to 
opening  the  pleural  cavity.  This  diminishes  by  so  much  the 
period  of  danger  in  collapse  of  the  lung. 

3.  The  use  of  Fell's  apparatus,  which  was  not  satisfactory  in 
this  case,  and  for  which  I  would  prefer  to  substitute  the  apparatus 
of  Dr.  Bloom,  of  New  Orleans,  which  I  have  the  pleasure  of 
showing  the  Fellows,  or  the  apparatus  of  Dr.  Matas,  which  he 
now  is  to  demonstrate  to  the  Fellows.  Probably  the  defective 
use  of  Fell's  apparatus  was  due  to  the  mask. 

4.  The  suture  of  the  lung  to  the  chest  wall.  This  was  fol- 
lowed by  no  untoward  surgical  result.  It  diminished  very 
greatly  the  amount  of  post-operative  pneumothorax,  and,  in 
fact,  one  might  almost  say  averted  it. 

5.  Whether  the  use  of  the  antistreptococcic  serum  was  the 


RESECTION    OF    THE    CHEST    WALL    FOR    A    SARCOMA.       39I 

cause  of  the  fall  of  temperature  or  only  a  coincidence  one  can 
hardly  say,  but  the  results  seemed  to  be  quite  striking. 

6.  The  examination  of  the  blood  was  of  great  value,  as 
showing  the  reason  for  the  continued  high  temperature,  and  led 
to  what  I  believe  to  have  been  the  proper  treatment  for  this 
condition. 

7.  It  is,  of  course,  too  early  to  determine  what  her  future  will 
be,  but  up  to  the  present  time,  a  period  of  nearly  seven  months, 
the  results  have  been  eminently  satisfactory,  no  recurrence  being 
yet  observed. 


ARTIFICIAL     RESPIRATION     BY      DIRECT    INTRA- 
LARYNGEAL  INTUBATION  WITH  A  MODIFIED 
O'DWYER  TUBE  AND  A  NEW  GRADUATED 
AIR-PUMP  IN  ITS  APPLICATIONS 
TO  MEDICAL  AND  SURGI- 
CAL PRACTICE. 


By  RUDOLPH  MATAS,  M.D., 

NEW   ORLEANS. 


In  two  communications,  one  contributed  to  the  Transactions 
of  the  Louisiana  State  Medical  Society,  in  May,  1898/  in  which 
I  suggested  the  advantages  of  the  Fell-O'Dwyer  apparatus  as  a 
means  of  preventing  and  overcoming  the  effects  of  acute  trau- 
matic pneumothorax  in  thoracic  operations,  and  the  other, 
pubhshed  in  the  Transactions  of  the  Southern  Surgical  and 
Gynecological  Association,  in  November,  1899,"  I  have  dis- 
cussed the  historical,  physiological,  surgical,  and,  to  some  extent, 
the  mechanico-therapeutical  phases  of  acute  traumatic  pneumo- 
thorax. In  these  communications  I  have  endeavored  to  demon- 
strate that  intralaryngeal  insufflation  is  a  most  valuable  auxiliary 
in  meeting  the  emergencies  of  surgical  practice  whenever  the 
respiratory  function  is  compromised  and  imperilled  by  acute 
surgical  atelectasis. 

While  especially  considering  the  advantages  of  insufflation  or 
artificial  respiration  with  mechanical  aids  in  its  applications  to 
thoracic  surgery,  and  more  particular  in  those  conditions  met  in 

1  The  Surgery  of  the  Chest,  etc.  Transactions  of  the  Louisiana  State  Medical  Society, 
May  10-12,  1898  ;  also  Annals  of  Surgery,  vol.  xxix.,  1899,  pp.  409-434. 

2  Intralaryngeal  Insufflation  for  the  Relief  of  Acute  Surgical  Pneumothorax,  etc., 
Transactions  of  the  Southern  Surgical  and  Gynecological  Association,  November,  1899 ; 
also  Journal  of  the  American  Medical  Association,  June  9,  1900. 


ARTIFICIAL   RESPIRATION   WITH    AN   o'dVVYER   TUBE,       393 

intrapleural  and  mediastinal  work  in  which  collapse  of  the  lungs 
occurs  in  consequence  of  the  sudden  entrance  of  air  into  the 
pleura  through  large  openings  or  fenestra  in  the  chest  wall,  I 
have  also  considered  the  advantages  of  mechanical  appliances  in 
maintaining  artificial  respiration  in  conditions  of  asphyxia  due 
to  other  non-surgical  causes.  Among  these  the  most  desirable 
is  a  reliable  means  of  maintaining  prolonged  artificial  respira- 
tion in  chloroform  and  ether  asphyxia;  in  acute  cocaine  poi- 
soning and  opium  narcosis ;  in  respiratory  failure  from  bulbar 
paresis — e.  g.^  in  drowning,  in  poisoning  from  illuminating  gas 
and  other  deoxidizing  gases ;  in  the  paresis  caused  by  the 
increased  intracranial  tension  due  to  cerebral  hemorrhage,  con- 
tusion, etc. 

Without  detaining  you  with  the  consideration  of  the  histori- 
cal and  evolutionary  phases  of  the  question,  which  I  have  fully 
presented  in  the  contributions  referred  to,  I  will  simply  recall 
the  fact  that  artificial  respiration  for  the  relief  of  asphyxia  due 
to  suffocation  and  drowning  had  already  attained  a  remarkable 
degree  of  development  as  early  as  1829,  when  various  pumps 
and  bellows  for  simple  insufflation  and  for  combined  insufflation 
and  aspiration  of  the  lung  had  been  devised  by  several  inge- 
nious experimenters  (Monroe's,  Goodwin's,  Hunter's,  Nooth's, 
John  Murray's,  Cap's,  among  others).  But  a  decided  setback 
was  given  to  the  practice  of  artificial  respiration  with  mechani- 
cal aids  by  the  exhaustive  experimental  research  undertaken  by 
Le  Roy  d'Etiolles  in  1829,  who,  in  a  memoir  addressed  to  the 
French  Academy  of  Sciences,  adversely  criticised  the  methods 
of  insufflation  then  in  vogue,  and  showed  their  objectionable 
and  dangerous  features  when  indiscriminately  and  unskil- 
fully applied.  He  based  his  conclusions  on  numerous  experi- 
ments made  on  rabbits,  foxes,  goats  and  sheep,  in  which  death 
had  been  observed  to  follow  with  alarming  frequency  as  a  result 
of  the  sudden  and  forcible  insufflation  of  air  into  the  trachea. 
The  French  Academy  appointed  a  special  committee,  consist- 
ing of  DumeriJ,  and  the  celebrated  physiologist,  Magendie,  who 
confirmed  Le  Roy's  observations,  and  extended  his  experiments 
to  the  dead  bodies   of  newborn  infants  and  adult  human  cadav- 


394  MAT  AS, 

ers.  These  observations  showed  that  the  sudden  violent  injec- 
tion of  air  into  the  lungs  often  caused  acute  emphysema,  rupture 
of  a  smaller  bronchi,  and  laceration  of  the  lungs,  with  the  pro- 
duction of  acute  pneumothorax  and  secondary  collapse  of  the 
lungs.  After  this  discouraging  report  nothing  was  done  to 
advance  the  practice  of  artificial  respiration  by  mechanical  aids 
until  1845,  when  a  new  movement  was  vigorously  started  in  its 
favor  through  the  exertions  of  Chaussier  and  Depaul,  the  emi- 
nent professors  of  obstetrics  at  the  Faculte.  Depaul,  who  was 
particularly  vigorous  in  his  agitation  of  the  subject,  and  his  fol- 
lowers only  developed  one  phase  of  the  question,  but  this  was 
in  a  very  important  direction,  viz.,  the  application  of  insufflation 
in  asphyxia  neonatorum  by  means  of  a  tube  introduced  directly 
into  the  larynx  through  the  glottis.  Intraglottic  tubes  of  various 
designs  were  devised  to  be  used  as  blow-pipes  by  the  opera- 
tor, or  were  connected  with  rubber  bulbs  which  forced  the  air 
into  the  larynx  through  the  canula.  Artificial  respiration  by 
intralaryngeal  intubation  and  insufflation  was  relegated  almost 
exclusively  to  the  accoucheur,  and  nothing  was  done  to  advance 
or  perfect  its  application  to  the  emergencies  of  surgery  until  the 
last  decade,  when  the  rapid  and  ever-increasing  assaults  made 
by  surgery  upon  the  lesions  of  the  intrathoracic  organs  aroused 
a  new  interest  in  the  literature  of  intrathoracic  operations  and 
created  a  demand  for  a  reliable  means  of  counteracting  the 
dangers  of  asphyxia  and  pneumothorax.  Quenu  and  Longuet^ 
Tuffier  and  Hallion,  Doyen  and  H.  Milton,  of  Cairo,  and  pos- 
sibly Pean,  had  all  realized  the  possibilities  of  mechanical 
insufflation,  and  had  made  notable  experimental  and  clinical 
contributions  to  the  technique  in  1897-1898,  but  with  the  excep- 
tion of  Doyen's  apparatus,  which  he  had  described  in  1898,  a 
simple  and  reliable  appliance  for  the  practice  of  artificial  respir- 
ation had  not  been  devised  or  put  to  the  test  of  clinical  experi- 
ence in  Europe. 

Doyen,  it  is  true,  had  invented  and  fully  described  his  com- 
pound bellows,  which,  when  attached  to  an  intralaryngeal 
canula,  was  capable  of  maintaining  rhythmical  artificial  respira- 
tion by  insufflation  and  aspiration.     This  apparatus  is  figured 


I 


ARTIFICIAL   RESPIRATION    WITH    AN    O   DVVYER   TUBE.      395 

in  his  Technique  Chmirgicale ,  published  in  1897,  but  there  is  no 
reference  in  his  book  or  his  subsequent  publications  to  any 
experimental  or  clinical  application  of  his  invention.  About 
this  time  (1897)  I  received  a  copy  of  the  medical  and  surgical 
reports  of  the  Presbyterian  Hospital  of  New  York  for  1896, 
which  contained  a  brief  but  excellent  article  by  Dr.  Northrup,  in 
which  he  demonstrated  the  value  of  the  Fell-O'Dwyer  appa- 
ratus as  an  aid  to  artificial  respiration  in  the  treatment  of  opium 
narcosis  and  other  non-surgical  conditions.  Too  much  credit 
cannot  be  given  Dr.  Northrup  for  his  persistent  advocacy  of  this 
valuable  apparatus,  the  invention  of  his  lamented  and  ingenious 
colleague,  O'Dwyer.  The  reading  of  this  article,  together  with 
the  repeated  demonstration  of  its  unfailing  and  almost  marvel- 
lous efficiency  in  cases  of  opium  narcosis  at  the  hands  of  Dr. 
J.  D.  Bloom,  surgeon  in  charge  of  the  Charity  Hospital  of  New 
Orleans,  immediately  suggested  to  my  mind  that  this  was  the 
apparatus  needed  in  thoracic  surgery. 

The  suggestion  grew  upon  me,  and  it  was  my  confidence  in 
its  value  that  led  me  to  take  it  as  a  basis  of  an  address  before 
the  Surgical  Section  of  the  Louisiana  State  Medical  Society  in 
May,  1898.  Since  then  the  clinical  confirmation  of  the  value 
of  the  principle  of  intralaryngeal  insufflation  in  overcoming  the 
collapse  of  the  lungs,  following  upon  the  resection  of  the  chest 
walls,  has  been  amply  confirmed  by  my  colleague.  Dr.  F.  W. 
Parham,  whose  able  and  exhaustive  monograph  on  the  "  Surgical 
Treatment  of  Tumors  of  the  Chest  Walls  ''  is  familiar  to  all 
those  who  have  followed  the  latest  developments  in  this  field 
of  thoracic  surgery.  The  interesting  case  just  reported  by  our 
distinguished  fellow,  Dr.  Keen,  also  illustrates  the  practice  of 
pulmonary  insufflation  to  overcome  the  collapse  of  the  lung  in 
traumatic  pneumothorax;  but  the  form  of  apparatus  used — i.  e., 
the  Fell  mask,  by  which  air  is  insufflated  by  the  oro-nasal 
method — is  liable  to  failure,  chiefly  from  the  dropping  of  the 
tongue  backward  and  the  introduction  of  air  into  the  pharynx 
instead  of  the  air  passages,  and  is,  therefore,  unreliable  as  a 
surgical  method,  more  especially  in  critical  conditions,  in  which 
certainty  and  precision  are  absolutely  necessary.     That  in  this 


396  MATAS, 

case  (Dr.  Keen's)  the  collapse  of  the  lungs  which  followed  the 
entrance  of  air  into  the  pleura  would  have  been  promptly  over- 
come if  an  intralaryngeal  canula  had  been  used,  as  in  Dr.  Par- 
ham's  case,  cannot  be  doubted.  The  recovery  of  the  patient  and 
the  absence  of  untoward  symptoms  when  the  pleura  was  opened 
simply  illustrate  the  fact  that  in  this,  as  in  other  recorded  cases, 
acute  surgical  pneumothorax  does  not  invariably  cause  an  arrest 
in  the  respiration  in  both  lungs  ;  but  in  man,  more  often  than 
in  dogs  and  other  lower  animals,  there  is  often  a  tolerance  to 
the  invasion  of  the  pleura  with  air,  provided  the  air  is  allowed 
to  enter  and  fill  the  pleura  gradually.  This  toleration  of  pul- 
monary collapse  in  some  cases  does  not  argue  that  the  occur- 
rence of  this  condition  is  free  from  peril ;  on  the  contrary,  the 
numerous  cases  that  have  been  recorded  (see  author's  contribu- 
tion to  the  surgery  of  the  chest^)  only  confirm  the  experimental 
evidence  which  conclusively  demonstrates  that  the  sudden  ad- 
mission of  air  in  the  pleura  through  q^large  fenestrum  is  one  of  the 
greatest  danger  elements  in  intrathoracic  surgery  and  one  of  the 
most  serious  obstacles  in  the  advancement  of  surgery  of  the  chest. 

It  would  now  appear  from  all  that  has  been  said  and  done 
that  no  further  discussion  could  be  called  for,  at  least  on  the 
value  of  a  reliable  apparatus  for  maintaining  artificial  respira- 
tion in  the  course  of  intrathoracic  operations.  But  a  little 
thought  and  experience  in  this  field  will  convince  us  that  the 
application  of  artificial  respiration  by  mechanical  devices  as 
applied  to  surgical  conditions  is  still  in  its  infancy,  and  that  the 
clinical  applications  of  intralaryngeal  insufflation  thus  far  made 
have  been  to  a  large  extent  empirical  and  justify  further  experi- 
mentation with  the  view  of  elevating  this  mode  of  treatment  to 
a  higher  plane  of  scientific  accuracy. 

There  are  also  certain  conditions  met  in  surgery  which  differ 
radically  from  the  conditions  met  in  purely  medical  cases,  and 
it  is  with  a  view  of  adjusting  our  resources  to  these  more  effec- 
tively that  I  have  continued  to  devote  much  time  and  thought 
to  the  mechanical  features  of  the  subject. 

1  Transactions  of  the  Louisiana  State  Medical  Society,  1899. 


ARTIFICIAL   RESPIRATION   WITH    AN   O  DWYER   TUBE.       397 

In  order  to  investigate  with  any  degree  of  accuracy  the  effects 
of  pulmonary  insufflation  by  the  intralaryngeal  method  upon 
the  lungs  in  normal  and  pathological  conditions,  the  first  requi- 
site was  a  suitable  apparatus  which  would  indicate  the  positive 
and  negative  variations  in  the  intrapulmonary  pressure  during 
insufflation  (inspiration)  and  expiration,  and  that  would  also 
provide  a  measure  and  means  of  controlling  the  quantity  of  air 
injected  into  the  trachea. 

It  was  evident  from  the  start  that  the  bellows  provided  with 
the  original  Fell-O'Dwyer  and  their  modifications  by  Dr.  Bloom 
and  myself,  or  by  the  Doyen  instrument,  could  not  be  utilized 
for  the  purpose,  and  that  an  entirely  new  apparatus,  based  upon 
the  principle  of  the  pump,  would  have  to  be  constructed  for  our 
experiments.  As  a  result  of  many  trials  with  different  models 
and  suggestions  the  machine  which  is  shown  in  Figs,  i  and  2, 
and  described  as  an  "  experimental  automatic  respiratory  appa- 
ratus," was  adopted.  In  the  construction  of  this  apparatus,  as 
well  as  in  devising  the  sequel  of  this,  which  is  our  practical  and 
latest  improved  single  cylinder  pump  for  clinical  use  (see  Figs. 
3  and  4),  I  have  had  the  benefit  of  the  collaboration  of  my 
assistant  and  friend.  Dr.  John  Smyth,  whose  training  and  skill 
as  a  mechanical  and  civil  engineer  have  been  most  helpful  in 
overcoming  the  mechanical  obstacles  met  in  perfecting  the 
working  details  of  these  appliances.^ 

The  idea  of  utilizing  an  automatic  respiratory  apparatus  on 
the  duplex  principle,  with  independent  inspiratory  and  expira- 
tory cylinders  or  pumps,  was  suggested  by  some  of  the  older 
appliances  devised  for  this  purpose,  and  especially  by  the  desire 
to  test  Doyen's  method  of  artificial  respiration  with  his  com- 
pound inspiratory  and  expiratory  bellows.  The  evident  object 
of  this  machine  was  to  simplify  the  work  of  the  operator 
in  applying  artificial  respiration  to  a  purely  mechanical  func- 
tion, so  that  once  the  intralaryngeal  canula  was  adjusted  in 
situ  the  work  of  insufflation  and  expiration  would  be  carried 

1  My  thanks  are  also  due  to  the  McDermott  Surgical  Instrument  Company  of  New 
Orleans,  who  manufacture  this  instrument!  for  their  valuable  co-operation  and  interest 
in  this  work. 


398  MAT  AS, 

on  automatically  by  the  machine.  As  will  be  seen  by  looking 
at  Figs.  I  and  2  and  the  accompanying  legends,  which  describe 
the  details  of  our  experimental  duplex  apparatus,  pump  I,  on 
backward  stroke,  aspirates  fresh  or  oxygenized  air  through  the 
inlet  valve  (IV),  and  during  forward  stroke  insufflates  it  into 
the  lungs  through  the  opening  in  the  cut-off  (V).  Pump  A,  on 
backward  stroke,  aspirates  the  vitiated  air  from  the  lungs 
through  cut-off  valve  (V),  and  in  forward  stroke  discharges  it 
through  outlet  valve  (OV).  The  mechanism  by  which  this 
alternate  insufflation  and  aspiration  is  due  is  clearly  explained 
by  the  legends  and  by  the  separate  diagram  of  the  cut-off. 
The  pumps  in  this  machine  were  made  to  work  independently 
of  each  other,  or  could  be  worked  together  if  desired,  and  were 
connected  with  a  manometer  which  accurately  indicated  all  the 
variations  in  the  intrapulmonary  pressure  during  inspiration 
and  expiration.  The  stroke-length  of  the  piston  in  both  pumps 
regulated  the  capacity  of  the  cylinders,  and  this  in  turn  was 
controlled  by  an  adjustable  screw  and  collar.  The  central 
piston  rod,  which  moved  the  cut-off  valve,  was  marked  into 
spaces  of  one  inch  each,  equivalent  to  about  4.4  cubic  inches  of 
air  per  inch,  as  determined  by  spirometric  tests.  The  total 
maximum  capacity  of  these  experimental  cylinders  was  nearly 
1500  c.c,  or  90  cubic  inches,  corresponding  to  the  average 
total  respiratory  capacity  of  a  single  lung  in  repose  (Landois). 

The  quantity  of  air  insufflated  and  the  intrapulmonary  press- 
ure could  be  rhultiplied  indefinitely  by  excluding  the  aspirating 
cylinder  (A)  and  preventing  the  escape  of  air  from  the  trachea 
while  working  the  inspiratory  cylinder  (I).  The  need  of  a 
powerful  pump  that  would  permit  of  an  indefinite  increase  in 
the  intrapulmonary  pressure  suggested  itself  in  view  of  our 
desire  to  test  the  resistance  of  the  lung  tissue  to  pathological 
pressure  and  to  determine  the  amount  of  air  and  the  pressure 
required  to  produce  emphysema,  laceration  of  the  lungs,  and 
other  pulmonary  lesions  by  violent  insufflation. 

When  the  large  duplex  pump  had  been  completed  it  was 
utilized  in  our  preliminary  experiments  on  dogs  and  human 
cadavers  to   familiarize  ourselves  not  only  with  the  technique 


ARTIFICIAL   RESPIRATION   WITH    AN   O   DWYER   TUBE.       399 

of  insufflation,  but  to  test  the  practicability  of  automatic  respira- 
tion in  which  the  cyUnders  were  used  to  alternately  pump  air 
into  and  out  of  the  lungs.  But  we  soon  found  out  that  there 
were  many  serious  obstacles  in  the  way  of  the  successful  appli- 
cation of  this  duplex  principle,  and  the  most  important  of  these 
was  the  damage  done  by  the  suction  force  exercised  by  the 
aspirating  cylinder  in  expiration.  The  aspiratory  action  of 
cylinder  (A)  caused  a  collapse  of  the  smaller  bronchial  tubes, 
which  are  not  sufficiently  cartilaginous  and  rigid  to  resist  even 
moderate,  slow  aspiration.  We  found  that  when  inspiratory 
pressure  on  insufflation  was  equal  to  +10-14  mm.  mercury, 
the  negative  pressure  or  expiration  was  —  20-24  mm.,  as  gauged 
by  the  manometer.  The  respiratory  movements,  under  these 
circumstances,  were  carried  on  at  the  rate  of  sixteen  times  per 
minute,  and  yet,  under  these  conditions,  a  general  collapse  of 
all  the  smaller  bronchi  took  place  in  both  lungs,  which  impris- 
oned the  vitiated  air  over  large  areas  with  each  expiration. 
Under  these  conditions  the  bronchi  are  opened  again  with  each 
insufflation,  but  the  deoxygenized  air  is  not  completely  released, 
and  thus  accumulates  in  the  air-cells,  thereby  increasing  the 
intra-alveolar  tension  to  such  an  extent  that  it  arrests  the  capil- 
lary circulation,  and  thus  defeats  the  essential  purpose  of  the 
mechanism.  If  the  suction  force  is  still  increased  by  increasing 
the  frequency  of  the  respiratory  rhythm,  then  a  vacuum  is  cre- 
ated in  the  larger  bronchi  as  well,  which,  when  frequently 
repeated,  induces  a  condition  of  hyper^emia,  paresis  of  the  ves- 
sels and  oedema  of  the  mucosa,  followed  by  extravasations 
which  permanently  damage  the  lung  and  still  further  cripple 
its  respiratory  function.  This  we  found  to  be  the  case  in  the 
lungs  of  the  dog  upon  which  we  performed  our  first  experi- 
ment, and  the  lesions  were  plainly  recognizable  during  life  and 
after  death.  The  evidence  obtained  in  this  experiment  promptly 
led  us  to  abandon  all  expectation  of  ever  utilizing  this  duplex 
method  in  practice. 

It  is  fortunate,  in  view  of  the  dangers  attending  the  use  of 
the  compound  inspiratory  and  expiratory  machines — which  for 
convenience  we  shall  continue  to  designate  as  the  "  duplex  " 


400  MATAS, 

machines  that  the  expiratory  part  of  the  respiration  aid  is 
unnecessary  in  practice,  and  that  all  that  is  required,  as  far  as 
the  expiration  is  concerned,  is  that  the  apparatus  used  shall  in- 
sufflate air  into  the  lungs  in  sufficient  quantity  and  under  proper 
pressure.  As  stated  by  O'Dvvyer  in  his  commentary  upon  the 
original  Fell  apparatus,  all  that  is  required  is  to  get  air  into  the 
lungs  and  give  it  sufficient  room  to  expand  and  time  to  escape, 
the  power  generated  and  stored  up  in  overcoming  the  resist- 
ance to  inspiration  being  amply  sufficient  to  carry  on  expiration. 

The  correctness  of  this  statement  is  well  borne  by  practical 
experience  with  the  Fell-0'Dwyer  apparatus,  and  is  fully  con- 
firmed by  our  experiments ;  but  the  dangers  which  attend  arti- 
ficial expiration,  or,  rather,  aspiration,  had  not  been  appreciated 
by  previous  experimenters,  if  we  are  to  judge  by  the  existence  of 
various  apparatus,  notably  the  ingenious  device  of  Doyen,  which 
have  been  created  for  the  purpose,  but  evidently  never  utilized 
in  practice. 

After  demonstrating  to  our  satisfaction  that  the  double  inspi- 
ratory and  expiratory  pump  was  not  a  practical  appliance  for  arti- 
ficial respiration,  we  abandoned  the  aspirating  cylinder  entirely 
in  our  work  and  utilized  the  single  insufflating  cylinder  (I,  Figs,  i 
and  2),  on  the  O'Dwyer  principle,  and,  having  found  it  perfectly 
reliable,  have  made  it  the  basis  of  our  practical  clinical  respira- 
tory machine  shown  in  Figs.  3  and  4.  Without  entering  into  a 
tedious  and  unnecessary  description  of  our  experiments  with 
this  pump  on  human  cadavers  and  dogs,  we  shall  simply  make 
a  few  statements  which  will  serve  as  conclusions  to  our  work, 
which  is  still  incomplete,  but  is  quite  sufficient  to  satisfy  us  of 
the  practical  working  qualities  of  the  apparatus  which  is  now 
exhibited  to  you.     (Figs.  3  and  4.) 

These  experiments  confirm  the  conclusions  already  established 
by  the  investigations  of  the  physiologists  (Bonders,  Landois, 
etc.)  and  of  the  surgeons  (Tuffier  and  Hallion),  to  the  effect  that 
the  intrapulmonary  pressure  required  to  overcome  the  elastic 
retractility  of  the  lungs  when  collapsed  by  the  admission  of 
air  into  the  pleura  is  very  slight,  and  that  positive  pressure  of 
6-8  mm.  mercury  is  quite  sufficient. 


ARTIFICIAL    RESPIRATION   WITH    AN   ODWYER   TUBE.      4OI 

In  a  human  adult  cadaver,  with  both  sides  of  the  thorax  widely 
opened  by  two  quadrilateral  fenestra  (4x5  inches),  the  lungs,  normal 
and  free  from  adhesions,  were  insufflated  with  the  respiratory  pump, 
the  modified  O'Dwyer  canula  (M.  F.,  Fig.  3)  being  introduced  into 
the  trachea.  The  stroke  of  the  piston  was  set  at  6^  inches  (^  about 
28  cubic  inches  of  air  per  stroke),  the  manometer  indicating+io  mm. 
pressure.  With  each  stroke  the  completely  collapsed  (normal)  lungs 
were  made  to  expand  and  project  beyond  the  line  of  the  chest  wall. 

In  the  same  subject,  with  a  4}4-inch  stroke  (19  cubic  inches  air  dis- 
placement), the  manometer  indicating  +  8  mm.  pressure,  the  lungs 
were  fully  expanded  and  held  against  the  chest  wall. 

Same  subject,  with  a  4-inch  stroke  (=17.6  cubic  inches)  and  a  press- 
ure of  -f-6  mm.  mercury,  the  lungs  were  expanded,  but  barely  touched 
the  ribs. 

In  another  cadaver,  adult,  male,  preserved  in  a  refrigerator  four 
weeks,  insufflation  was  tried  with  the  same  pump  without  opening  the 
chest.  Our  pump  working  with  a  10^ -inch  stroke  (=  45  cubic  inches 
of  air  displaced  with  each  stroke)  and  the  manometer  indicating  10  mm. 
mercury,  the  cadaveric  rigidity  of  the  diaphragm  and  the  chest  was 
overcome  and  the  chest  expanded  with  marked  bulging  at  the  inter- 
costals  and  epigastrium.  In  this  way  the  cadaver  was  made  to  breathe 
rhythmically  at  the  rate  of  eighteen  to  twenty  times  per  minute. 

A  pressure  of  8  mm.  mercury  was  found  to  be  quite  sufficient  to 
expand  the  lungs  in  another  adult  male  subject  upon  which  we  experi- 
mented twelve  hours  after  death.  In  this  case  the  cadaveric  rigidity 
was  less,  and  the  expansion  of  the  chest,  produced  by  a  full  inspira- 
tion, was  easily  obtained  with  a  displacement  of  45  inches  per  stroke  of 
the  pump. 

The  following  experiment  on  a  dog  was  also  instructive. 

A  medium  size  mongrel  cur  was  anaesthetized  with  chloroform  by  the 
usual  oro-nasal  method ;  after  relaxation  had  been  obtained  the  intra- 
laryngeal  canula  was  introduced  into  the  glottis,  and  chloroform  was 
continued  through  the  canula  until  anaesthesia  was  complete.  The  fun- 
nel of  the  inhaler  was  then  attached  to  the  inlet  of  the  insufflating 
pump,  and  the  insufflating  pump  was  set  so  that  each  stroke  of  the  pis- 
ton displaced  45  cubic  inches  per  stroke.  A  large  osteoplastic  thorac- 
otomy was  performed,  and  the  right  pleura  was  rapidly  exposed  by 
cutting  a  large  quadrilateral  flap  measuring  4x5  inches.  The  bleed- 
Am  Surg  26 


402  MAT  AS, 

ing  from  the  intercostals  was  surprisingly  small.  The  lung  immedi- 
ately collapsed,  and  respiration  ceased  at  once.  The  pump  was  then 
set  into  operation  at  the  rate  of  about  eighteen  times  a  minute.  The 
lung  immediately  expanded  to  the  full  limit  of  the  chest  wall,  showing 
a  tendency  to  prolapse  through  the  fenestrum.  With  aspiration  (the 
aspirating  cylinder  being  used)  the  lung  receded  as  in  expiration,  and 
the  rhythm  of  the  respiration  was  kept  up  for  over  four  minutes,  dur- 
ing which  the  circulation  was  restored  and  the  animal  appeared  to 
recover  from  the  shock.  During  this  time  the  demonstration  of  the 
efficacy  of  insufflation  could  not  have  been  more  satisfactory  or  con- 
clusive. We  were  able  to  manipulate  the  lung  freely  while  it  was  alter- 
nately expanding  and  contracting,  and  had  no  difficulty  in  reaching 
the  hilum  of  the  organ  and  feeling  it  as  well  as  the  pulsating  heart  and 
great  vessels.  If  we  had  then  closed  the  chest  we  believe  the  animal 
would  have  survived  the  ordeal ;  but  we  were  curious  to  try  the  suture 
of  the  lung  and  other  surgical  procedures,  and  while  preparing  to  do 
this  we  observed  that  the  expiratory  retreat  of  the  lung  became  more 
feeble  and  that  the  lung  failed  to  empty  itself.  This  we  attributed  to 
the  powerful  suction  of  the  aspirating  cylinder,  which  interfered  with 
complete  expiration  by  creating  too  great  a  vacuum  in  the  bronchi. 
While  observing  this  phenomenon  the  animal  became  cyanosed  and  the 
heart's  action  feeble  and  irregular.  In  the  meantime  the  assistant  in 
charge  of  the  canula  accidentally  allowed  this  to  become  displaced,  and 
the  air  was  pumped  into  the  oesophagus,  causing  an  enormous  distention 
of  the  stomach,  which  still  further  interfered  with  the  action  of  the  dia- 
phragm. Before  this  accident  could  be  remedied  the  animal  died.  It 
was  plain  to  all  that  if  in  this  case  only  the  single  insufflating  cylinder 
had  been  used,  or  that  the  aspirating  cylinder  had  been  promptly  dis- 
connected and  expiration  allowed  to  take  place  through  the  canula, 
that  death  would  not  have  occurred. 

The  fact  remains,  however,  that  insufflation  did  very  promptly  over- 
come the  collapse  of  the  lung  which  followed,  with  arrested  respira- 
tion, the  moment  the  pleura  was  widely  opened.  It  is  also  positive 
that  the  animal  would  have  perished  promptly  when  this  happened 
had  not  the  insufflation  immediately  revived  him  by  restoring  the 
respiration. 

Other  experiments  were  performed  to  test  the  amount  of  press- 
ure required  to  destroy  the  elasticity  of  the  lungs  and  to  produce 
emphysema  by  rupture  of  the  air  cells,  and  while  these  are  still 


ARTIFICIAL    RESPIRATION    WITH    AN    O   DWYER   TUBE.      4O3 

incomplete  we  believe  it  safe  to  assert  that  as  long  as  the  intra- 
pulmonary  pressure  of  the  air  insufflated  is  not  sufficient  to  cause 
the  lung  to  be  herniated  beyond  the  chest  wall,  there  is  no  seri- 
ous risk  of  traumatic  emphysema  in  intrapleural  operations.  In 
fact,  we  have  been  struck  in  our  experiments  on  the  cadaver  and 
dog  by  the  enormous  resistance  of  the  lung  tissue  to  laceration. 
The  lung  apparently  recovers  promptly,  even  its  normal  respira- 
tory capacity  is  doubled.  In  a  dog  of  medium  size  from  looo 
to  1500  c.c.  were  required  to  cause  serious  permanent  emphy- 
sematous lesions.  Further  experimental  evidence  is  still  required 
to  study  the  exact  conditions  under  which  these  pathological 
lesions  are  produced.  It  is  also  quite  possible  that  minute  his- 
tological lesions  are  caused  by  even  moderate  over-distention 
which  has  escaped  the  gross,  naked-eye  observations  which  we 
have  made. 

The  most  important  part  of  our  work  still  remains  to  be  com- 
pleted, and  that  is  the  practical  experimental  study  of  pulmo- 
nary and  mediastinal  surgery  under  the  new  conditions  of  aided 
respiration.  That  much  can  be  learned  in  this  field  by  repeat- 
ing in  a  systematic  way  many  of  the  older  experiments  of  Bloch, 
Marcus,  Schmid,  Biondi,  Willard  and  others,  cannot  be  denied. 
In  the  meantime  the  means  of  applying  artificial  respiration  with 
an  apparatus  which  can  be  readily  and  safely  applied,  which 
will  accurately  register  the  intrapulmonary  pressure  during 
insufflation,  and  will  permit  the  operator  to  regulate  the  quantity 
of  air  insufflated,  is  necessary  for  experimental  work  and  is  very 
desirable  in  actual  practice.  Without  wishing  to  disparage  or 
minimize  in  the  least  the  excellent  service  which  the  Fell- 
O'Dwyer  apparatus  and  its  modifications  have  rendered  and  are 
capable  of  rendering  in  medical  practice,  we  believe  there  is  a 
place  for  such  an  apparatus  as  I  now  have  the  pleasure  of  sub- 
mitting to  you.  The  chief  objection  to  the  bellows  as  an  insuf- 
flating agent  is  that  its  insufflating  capacity  cannot  be  regulated 
or  graduated,  and  that  it  is  capable  of  insufflating  at  best  only 
a  fixed  quantity  of  air.  We  have  tested  all  the  bellows  now  in 
use  for  the  purpose  (original  Fell,  Fell-0'Dwyer,  and  its  modi- 
fication  by  Dr.  Bloom),  and  these  are  capable  of  a  maximum 


404  MATAS, 

displacement  of  45  cubic  inches  of  air.  While  this  quantity  is 
far  in  excess  of  that  required  to  overcome  the  elastic  retrac- 
tility of  the  collapsed  lung  when  the  chest  is  opened  (28  cubic 
inches  being  amply  sufficient  in  healthy  lungs),  the  empirical 
insufflation  of  the  excess  of  air  discharged  by  the  bellows  is 
not  excessive  or  injurious  when  artificial  respiration  is  practised 
on  the  closed  chest  with  a  pressure  of  6  mm.  in  cases  of  arrested 
respiration.  The  more  serious  objection  to  the  bellows  is  that 
it  is  incapable  of  sustaining  intrapulmonary  pressure  long  enough 
during  the  periods  of  inspiration  (insufflation)  to  favor  surgical 
action  in  open  cases.  The  bellows  will  distend  the  lungs  fully 
when  the  respiratory  movements  are  kept  going  at  the  rate  of 
20  insufflations  per  minute ;  but  whenever  this  rhythm  is  mod- 
erated in  frequency  to  10  or  12  complete  respirations  per  min- 
ute or  less,  the  lungs  empty  themselves  before  the  next  insuffla- 
tion is  ready  to  fill  them  again.  This  is  caused  by  a  backward 
leakage  into  the  bellows,  while  the  finger  which  controls  the 
outlet  of  the  laryngeal  canula  continues  to  stop  the  opening. 
In  other  words,  the  duration  of  the  inspiration  cannot  be  con- 
trolled by  the  will  of  the  operator.  With  our  pump,  on  the 
other  hand,  the  pulmonary  distention  obtained  by  the  inspira- 
tory insufflation  is  not  lost  by  leakage,  and  is  sustained  as  long 
as  the  expiratory  outlet  in  the  canula  is  stopped  by  the  thumb 
of  the  operator.  In  this  way  the  rhythm  of  the  respiration  can 
be  regulated  by  the  operator,  which  is  a  distinct  advantage  in 
operative  work. 

The  difference  in  the  action  of  the  pump  and  bellows  is  in  this 
respect  well  shown  by  a  simple  demonstration  with  the  artificial  lungs 
that  we  have  extemporized  for  the  purpose.  The  model  which  I  now 
show  you  has  been  made  by  attaching  a  pair  of  rubber  toy  balloons  to 
a  human  larynx  and  trachea.  The  balloons  are  connected  separately 
to  each  one  of  the  primary  bronchi,  which  remain  as  a  part  of  the 
bifurcation.  If  we  now  intubate  the  larynx  with  the  O'Dwyer  canula 
and  insufflate  with  the  bellows  you  will  see  that  the  balloons  become 
distended  to  their  full  capacity,  but  this  distention  is  followed  by  an 
immediate  collapse,  which  begins  before  1  have  time  to  compress  the 
bellows  again.  This  happens  in  spite  of  the  fact  that  I  have  theexpira- 


ARTIFICIAL   RESPIRATION   WITH    AN   o'dWYER   TUBE.      4O5 

tory  outlet  in  the  laryngeal  canula  closed.  As  the  connections  are  all 
air-tight,  it  is  evident  that  there  is  no  exit  for  the  air  in  the  lungs  except 
through  the  bellows.  If  the  same  experiment  is  repeated  with  our 
pump  you  will  see  that  the  balloons  remain  distended  fully  until  I 
release  the  confined  air  by  withdrawing  my  finger  from  the  outlet  in 
the  canula. 

If  we  now  summarize  the  peculiarities  of  this  apparatus  for 
artificial  respiration  (see  Figs.  3  and  4)  we  will  state — 

1.  That  it  is  a  graduated  pump  which  can  be  readily  adjusted 
to  any  quantity  of  air  required  from  i  to  700  cm,  (or  i  to  43 
cubic  inches). 

2.  That  it  is  provided  with  a  mercurial  manometer,  which 
indicates  the  intrapulmonary  pressure  and  is  an  index  to  the 
peripheral  resistance  that  is  overcome  by  the  insufflation. 

3.  That  it  is  provided  with  an  automatic  cut-off  which  effec- 
tively prevents  any  backward  leakage  of  air  into  the  cylinder, 
and  thus  puts  the  inspiratory  inflation  of  the  lungs  under  the 
control  of  the  operator,  thus  regulating  the  duration  of  the 
inspiratory  act  and  thereby  the  rhythm  of  the  respiration. 

4.  It  is  provided  with  an  air  filter  interposed  between  the 
larynx  and  the  pump,  which  purifies  the  air  injected  through 
the  pump. 

5.  The  inlet  opening  of  the  pump  can  be  readily  adjusted  to 
a  screened  funnel  and  tube  for  further  administration  of  chloro- 
form or  oxygen  while  artificial  respiration  is  going  on. 

6.  It  is  provided  with  an  intralaryngeal  canula  of  the  O'Dwyer 
type,  with  several  adjustable  conical  tips  for  intubation.  Our 
modified  canula  differs  from  the  O'Dwyer  canula  in  the  shape 
of  the  handle,  which  is  pistol-shaped  and  gives  a  firm  grip,  and 
in  having  an  opening  guarded  with  a  stopcock  which  is  easily 
connected  to  a  tube  and  funnel  for  the  administration  of  chloro- 
form while  the  patient  is  breathing  through  the  intubating 
canula.  While  insufflation  is  going  on  the  stopcock  is  closed 
and  the  anaesthetic  is  administered  through  the  inlet  in  the 
pump. 

In  applying  this  apparatus  the  intubating  end  of  the  canula  is 
introduced  into  the  space  above  the  vocal  cords  bounded  by 


406  M  A  T  A  S  , 

the  aryteno-epiglottic  folds  and  epiglottis.  In  some  cases  the 
smaller  conical  tips  may  be  introduced  as  an  ordinary  intu- 
bating canula  between  the  vocal  cords  ;  but  in  the  majority  of 
cases  this  is  unnecessary,  as  the  conical  graded  tips  furnished 
with  the  original  O'Dwyer  canula  can  be  accurately  adjusted  to 
supraglottic  space,  where  it  is  firmly  held  in  place  by  the  epi- 
glottis, the  arytenoids,  and  the  aryteno-epiglottic  folds.  The 
adjustment  of  the  intralaryngeal  tips  requires  a  certain  experi- 
ence and  dexterity,  which  are  generally  obtained  after  a  few 
attempts,  but  are  better  acquired  by  a  preliminary  experience 
on  the  cadaver.  The  long  handle  and  firmness  of  the  metallic 
canula  greatly  facilitate  the  manoeuvre  required  in  fitting  the 
intubating  tips  to  the  glottic  opening.  In  this  respect  the 
O'Dwyer  canula  is  easier  to  handle  and  to  adjust  than  the 
short  intralaryngeal  tube  devised  by  Doyen,  which  requires  for 
its  introduction  the  special  long  forceps  which  he  has  devised. 
In  applying  intubation  for  insufflation  the  preliminary  anaes- 
thesia of  the  patient  is  required,  unless  he  be  already  uncon- 
scious and  anaesthetic  from  the  effects  of  asphyxia,  shock,  or 
narcotic  poisons.  After  the  patient  is  relaxed  by  the  anaes- 
thetic the  introduction  of  the  intralaryngeal  canula  is  much 
simplified.  Once  the  canula  is  in  place  it  may  be  necessary  to 
continue  the  anaesthesia.  This  can  be  very  readily  done  by 
attaching  the  funnel-shaped  inhaler  to  our  canula.  In  the 
meantime  the  connections  with  the  respiratory  cylinder  are 
adjusted  and  kept  in  readiness  for  insufflation  the  moment  the 
operator  may  deem  it  necessary.  When  the  pump  is  set  in 
operation  the  stopcock  which  guards  the  opening  of  the  inhaler 
is  closed  in  order  that  the  insufflated  air  may  not  escape  through 
the  inhaler.  The  inhaling-tube  and  funnel  are  then  transferred 
and  attached  to  the  inlet  of  the  pump  itself,  so  that  anaesthesia 
may  be  continued  if  desired  while  artificial  respiration  is  going 
on.  It  is  also  a  very  simple  matter  to  attach  the  discharging 
tube  of  an  oxygen  cylinder  to  the  inlet  of  the  pump  if  the  use 
of  this  gas  be  especially  indicated.  In  using  the  pump  on 
adults  it  will  be  well  to  adjust  the  piston  so  that  the  full  capacity 
of  the  pump  (43  cubic  inches)  be  administered  in  the  start,  after 


ARTIFICIAL   RESPIRATION   WITH    AN   o'dWYER   TUBE.      407 

which  the  quantity  of  air  may  be  regulated  according  to  the 
effect  observed  on  the  lung  itself  in  open  cases  or  on  the  chest 
walls  and  diaphragm  when  the  chest  is  closed,  as  in  non-surgi- 
cal conditions.  If  the  amount  of  air  insufflated  is  excessive 
the  lung  will  have  a  tendency  to  become  herniated  through  the 
opening  made  in  the  chest  walls,  and  the. capacity  of  the  pump 
should  be  regulated  by  the  screw  and  collar  on  the  piston  until 
the  proper  distention  is  obtained — i.  e.,  just  enough  to  make 
the  lungs  touch  the  chest  wall  in  full  inspiration.  The  normal 
pressure  required  to  obtain  this  pressure  is  6  to  8  mm.,  as  indi- 
cated by  the  manometer.  .  The  manometer  is  especially  useful 
in  indicating  cumulative  or  excessive  pressure  in  the  lungs, 
more  particularly  in  closed  cases.  It  will  help  to  regulate  the 
rhythm  of  the  respiration  and  to  prevent  too  rapid  or  frequent 
insufflations,  which  would  overstretch  the  alveoli  and  thus 
defeat  the  purpose  of  the  insufflation,  a  pressure  of  30  or  more 
mm.  being  sufficient  to  stop  the  aerating  function  of  the  lungs, 
the  manometer  in  this  and  other  ways  being  quite  a  useful 
adjunct  to  the  apparatus. 

In  applying  artificial  respiration  with  this  pump  (which  will 
only  open  or  close  with  the  full  excursion  of  the  piston),  it  will 
be  found  that  the  respiratory  movements  will  be  carried  on  with 
a  regularity,  fulness,  and  deliberation  that  are  scarcely  possible 
with  the  bellows.  The  duration  of  each  inspiratory  insufflation 
will  be  controlled  by  the  finger  of  the  operator  which  closes 
the  outlet  in  the  handle  of  the  canula.  As  long  as  the  thumb 
occludes  this  outlet  the  insufflated  air  will  be  retained  in  the 
chest  and  the  distention  of  the  lung  will  be  maintained.  It  is 
only  when  the  thumb  is  lifted  from  the  opening  that  the  im- 
prisoned air  in  the  lungs  escapes  and  that  expiration  takes 
place.  In  this  way  the  rhythm  of  the  respiration  can  be  regu- 
lated, so  that  it  may  be  very  rapid  or  slow  according  to  the 
needs  of  the  case. 

We  regret  very  much  that  the  opportunity  has  not  yet  pre- 
sented itself  to  apply  this  pump  on  the  living  subject,  but 
our  experience  with  it  on  the  cadaver  and  dog  fully  demon- 
strates its  practical  working  capacity.    In  submitting  this  appli- 


408  MATAS, 

ance  to  the  Association  we  do  not  pretend  to  have  reached  the 
ideal  apparatus ;  on  the  contrary,  we  do  not  doubt  that  in  the 
course  of  further  experimentation  other  suggestions  may  be 
made  which  will  contribute  to  its  simplicity  and  usefulness. 
It  is  the  outcome  of  our  efforts  in  meeting  the  necessities  of 
experimentation,  and  in  the  hope  that  it  may  prove  useful  to 
other  investigators  and  surgeons  who  are  interested  in  the 
development  of  a  most  promising  field  of  surgical  advancement, 
we  gladly  submit  it  to  the  profession. 


EXPERIMENTAL  AUTOMATIC  RESPIRATORY  APPARATUS, 

WITH   INDEPENDENT   INSPIRATORY  AND   EXSPIRATORY  CYLINDERS  OR  PUMPS,  FOR 
THE  PURPOSE  OF  MAINTAINING  RHYTHMICAL  ARTIFICIAL  RESPIRATION. 

Pump  I,  on  backward  stroke,  aspirates  fresh  or  oxygenized  air  through  inlet  valve  IV, 
and  during  forward  stroke  insufflates  it  into  the  lungs  through  opening  in  cut-off  V. 

Pump  A,  on  backward  stroke,  aspirates  vitiated  air  from  lungs  through  cut-off  valve  V, 
and  on  forward  stroke  discharges  it  through  outlet  valve  OV. 

LEGEND   TO    FIGS.  I    AND    2. 

H.  Handle  common  to  P  and  the  two  pump  pistons. 

P.  Accessory  piston  for  automatic  cut-off. 

S.  Sliding  tube  for  automatic  cut-off. 

A.  Aspirating  pump. 

I.  Inspirating  pump. 

C.  Adjustable  collar  for  automatic  cut-off  and  regulating  stroke. 

IV.  Inlet  valve  for  o.\ygenized  or  medicated  air. 

L.  Compound  lever  for  automatic  cut-off. 

V.  Valve  or  stopcock  for  automatic  cut-off. 

OV.  Outlet  valve  for  discharge  of  respired  air. 

F.  Stopcock  to  disconnect  pump  A. 

R.  Rubber  tube  to  intubating  apparatus. 

T.  Glass  T  connecting  manometer  tube. 

SR.  Small  rubber  tube  connecting  with  manometer. 

MF.  Modified  O'Dwyer  intubating  apparatus,  with  thumb  opening  closed  with  rubber 
stopper. 

M.  Mercurial  manometer,  reading  in  millimetres  to  200,  pressure  or  vacuum. 

Notes. 

To  allow  the  double  yet  independent  action  of  these  pumps  an  automatic  cut-off  was 
necessary.  This  was  accomplished  by  the  modified  stopcock  V  attached  by  the  com- 
pound lever  L  to  sliding  tube  S,  which  was  moved  by  the  accessory  piston-rod  P  attached 
to  the  common  handle  H.     This  piston  P,  having  a  knob  on  its  free  end,  travels  in  S, 


Fig.  I. 


Fig.  2. 


Experimental  Automatic  Respiratory  Apparatus  with  Double  Inspiratory  and  Expiratory  Cylindtrs. 


ARTIFICIAL   RESPIRATION    WITH    AN    o'dWYER   TUBE.      4O9 

and  when  about  one  and  a  half  inch  from  limit  of  forward  stroke  it  strikes  the  end  of 
the  tube,  driving  it  forward  and  pushing  the  lever  of  stopcock  V  through  arc  of  90°  (see 
Fig.  I  and  dotted  line  in  diagram),  thus  closing  communication  of  pump  I  with  tracheal 
tube  R,  and  opening  communication  of  R  with  pump  A. 


INSPlRATING  PUMP 

IV 

r^^ 

1 

U 

INL 

^^ 

\-: 

,-'- 

INLET  FLAP  VALVE 


OUTLET  FLAP  VALVE 
wrTH  GOIL  SPRING 


In  the  sliding  tube  S,  almost  its  entire  length  is  a  slot ;  on  the  tube  is  an  adjustable 
collar  C  with  a  thumbscrew  to  clamp  it  at  any  point ;  in  this  collar  and  projecting  through 
the  slot  is  a  screw  against  which  the  knob  of  accessory  piston  P  strikes  when  within  one 
and  a  half  inch  limit  of  backward  stroke  ;  this  final  one  and  a  half  inch  of  stroke  then 
moves  the  tube  S  which  causes  cut-off  at  V  as  before,  but  in  opposite  direction,  closing 
communication  of  pump  A  with  tracheal  tube  R  and  opening  communication  between 
tracheal  tube  and  pump  I.     (See  diagram.) 


4IO 


MATAS. 


APPARATUS  FOR  ARTIFICIAL  RESPIRATION  IN  SURGICAL  AND 
MEDICAL  PRACTICE  (LATEST  MODEL), 

WITH   AUTOMATIC  CUT-OFF   AND   ATTACHMENT   FOR   GOVERNING  STROKE  OF 
PUMP   AND   REGULATING  AMOUNT  OF   AIR   INSUFFLATED. 

Pump  A,  on  backward  stroke,  receives  fresh  or  medicated  air  through  opening  at  I, 
and  during  forward  stroke  insufflates  it  into  lungs  through  opening  in  cut-off  V.  Ex. 
piration  is  accoraphshed  through  opening  in  modified  O'Dwyer  intubation  canula  by 
operator  removing  thumb  from  outlet  O. 

LEGEND   TO   FIGS.  3   AND   4. 

H.  Handle  common  to  P  and  the  pump  piston. 

P.  Accessory  piston  for  automatic  cut-off. 

S.  Sliding  tube  for  automatic  cut-off. 

C.  Adjustable  collar  for  automatic  cut-off  and  regulating  stroke. 

I.  Inlet  for  fresh  or  medicated  air. 

L.  Compound  lever  for  automatic  cut-off. 

V.  Valve  or  stopcock  for  automatic  cut-off. 

F.  Cylinder  containing  absorbent  cotton  for  filtering  air. 

R.  Rubber  tube  to  intubating  apparatus. 

T.  Glass  T  connecting  manometer  tube. 

SR.  Small  rubber  tube  connecting  with  manometer. 

MF.  Modified  O'Dwyer  intubating  canula  and  stopcock  attachment  for  chloroform 
anaesthesia. 

M.  Mercurial  manometer,  reading  in  millimetres  to  sixty,  pressure  or  vacuum. 

Notes. 
To  obviate  the  use  of  flap  or  ball  valves  which  present  a  considerable  factor  of  uncer- 
tainty, an  automatic  cut-off  with  positive  stopcock  was  adopted  (Dr.  Smyth's  sugges- 
tion).    The  modified  stop-cock  V  attached  by  the  compound  lever  L  to  the  sliding  tube 
S  is  moved  by  accessory  piston  P  attached  to  the  common  handle  H. 


PUMP  CYLINDER 


The  piston  P,  having  a  knob  on  its  free  end,  travels  in  S,  and  when  ^^„  inch  from 
limit  of  forward  stroke  it  strikes  the  end  of  the  tube,  driving  it  forward  and  pushing  the 


Fig.  3 


Fig.  4. 


Latest  Working  Model  of  Apparatus  for  Artificial  Respiration  in  Medical  and  Surgical  Practice. 


ARTIFICIAL   RESPIRATION   WITH    AN   O  DVVYER   TUBE.      4II 

lever  of  the  stopcock  V  through  arc  of  45°  (see  Fig.  3,  L,  and  dotted  line  in  diagram), 
thus  closing  communication  of  pump  with  tracheal  tube  and  opening  communication 
with  I. 

In  sliding  tube  S  almost  its  entire  length  is  a  slot,  on  the  tube  is  an  adjustable  collar  C 
with  a  thumbscrew  to  clamp  it  at  any  point;  in  the  collar  and  projecting  through  the 
slot  is  a  screw  against  which  the  knob  of  the  accessory  piston  P  strikes  when  within  ^^ 
of  an  inch  of  limit  of  backward  stroke,  thus  moving  the  tube  S  which  causes  cut-off  at 
V  as  before,  but  in  opposite  direction,  closing  communication  of  pump  with  inlet  I  and 
opening  communication  with  tracheal  tube  (see  diagram). 

The  sliding  tube  S  is  graduated  on  each  side  of  the  slot,  on  left  side  in  cubic  inches  to 
45,  and  on  right  side  cubic  centimetres  to  700,  relative  to  pump  capacity. 

Filter  F  is  one  and  a  half  by  two  and  a  quarter  inches,  filled  with  absorbent  cotton  to 
prevent  oil  or  other  no.xious  materials  from  entering  tracheal  tube. 

Vaseline  has  been  used  in  pump  instead  of  sperm  or  cylinder  oil,  it  having  no  odor. 

Manometer  M  is  made  of  one-sixth  inch  glass  tubing  on  the  open  principle. 

Intubation  canula  differs  from  the  O'Dwyer  canula  in  (i)  the  shape  of  the  handle 
which  forms  the  grasp  of  the  instrument,  while  the  thumb  of  the  operator  controls  the 
expiratory  outlet;  (2)  in  the  addition  of  an  attachment  and  stopcock  for  a  chloroform 
inhaler  of  the  Trendelenburg  funnel  type.  In  this  way  anaesthesia  can  be  continued  or 
interrupted  while  the  canula  is  in  the  larynx.  As  long  as  artificial  respiration  is  not 
required  the  chloroform  is  administered  directly  through'  the  canula  inhaler ;  when  the 
pump  is  in  operation  the  anaesthetic  attachment  is  removed,  stopcock  closed,  and  in- 
haler attached  to  pump-inlet  I. 

The  pump  is  made  of  one-sixteenth  inch  copper  tubing  two  and  one-half  inches  in 
diameter  and  ten  and  one-half  inches  long,  having  total  effective  capacity  of  43  cubic 
inches,  700  cubic  centimetres,  with  nine  and  eight-tenths  inches  stroke,  or  4.388  cubic 
inches  capacity  per  inch  of  stroke. 


AN  APPARATUS  FOR   MASSIVE  INFILTRATION 

ANESTHESIA   WITH   WEAK   ANALGESIC 

SOLUTIONS  (MODIFIED  SCHLEICH 

METHOD). 


By  RUDOLPH  MATAS,  M.D. 

NEW   ORLEANS,  LA, 


In  a  paper  on  "  Local  and  Regional  Anaesthesia,"  published 
in  the  Philadelphia  Medical  Journal,  November  3,  1900,  I  de- 
scribed and  illustrated  a  simple  apparatus  which  I  had  used 
extensively  since  March,  1900,  in  the  practice  of  local  and 
regional  anaesthesia,  with  weak  solutions,  by  the  Schleich 
method. 

The  advantages  of  an  injecting-bottle,  by  which  the  anaes- 
thetizing solution  could  be  forced  (by  pneumatic  pressure)  in 
large  quantities  into  the  tissues  continuously  and  without  ne- 
cessitating the  frequent  interruptions  caused  by  refilling  even 
large  antitoxin  syringes,  occurred  to  me  while  applying  subcu- 
taneous gelatin  injections  in  the  treatment  of  inoperable  aneu- 
rism by  Lancereaux's  method.  After  a  few  trials  of  the  new 
device  I  abandoned  the  syringes  and  substituted  the  apparatus 
described  in  the  article  referred  to.  It  consisted  essentially  of 
two  parts.  One,  a  strong  graduated  glass  nursing-bottle  (8-ounce 
capacity)  and  a  pump,  the  ordinary  pump  of  a  Potain  aspi- 
rator, with  the  necessary  rubber  tubing  and  metallic  connec- 
tions, by  which  air  could  be  forced  into  the  bottle.  The  bottle 
was  provided  with  the  perforated  rubber  stopper  holding  the 
metallic  Y  tube  of  the  Potain  bottle,  which  was  held  firmly  in 
the  bottle  by  a  special  metallic  clamp  and  collar,  which  pre- 
vented the  stopper  from  being  blown  off  by  the  compressed  air 


Fig.  I. 


Apparatus  for  rapid,  massive  infiltration  anaesthesia.     Charging  the  cylinder  with  air  pump. 

(Dr.  Matas.1 

Fig.  2. 


Cylinder  charged  and  inverted.     The  pumping  outfit  is  detached  when  the  apparatus 

is  in  operation. 


APPARATUS    FOR     INFILTRATION    AN/ESTHESIA.      4I3 

in  the  bottle.  The  bottle  was  charged  with  the  pump  until  the 
resistance  felt  in  the  piston  indicated  that  the  limit  of  pneumatic 
compression  had  been  reached.  Usually  ten  to  twelve  pump- 
ings  with  the  Potain  pump  sufficed  to  charge  the  bottle  suf- 
ficiently to  force  the  contents  out  of  the  bottle  until  this  has 
been  completely  emptied.  After  charging  the  bottle  the  pump 
was  disconnected,  and  the  charged  reservoir  remained  in  the 
hands  of  the  assistant,  who  held  it  while  the  operator  directed 
the  flow  of  the  anaesthetizing  solution  by  means  of  the  needle 
and  discharge  tube.  The  flow  of  the  fluid  was  perfectly  con- 
trolled by  the  stopcock  at  the  Y  tube. 

I  utilized  this  simple  and  easily  improvised  contrivance  in  a 
very  extensive  series  of  minor  and  major  operations,  and  would 
still  continue  to  use  it  had  it  not  been  that  in  consequence  of 
repeated  accidents  caused  by  the  breaking  of  the  bottle,  I  real- 
ized that  a  strong  metallic  receptacle  was  necessary.  I  found 
that  in  dealing  with  dense  and  especially  chronically  inflamed 
tissues  the  pressure  required  to  force  the  fluid  into  the  tissues 
subjected  the  bottle  to  a  dangerous  strain,  causing  explosions, 
especially  when  the  charging  of  the  bottle  was  intrusted  to 
inexperienced  assistants. 

The  bottle  under  these  circumstances  would  break  into  frag- 
ments, which  would  have  cut  the  hands  of  the  assistants  had 
not  the  precaution  been  takeato  wrap  the  bottle  in  sterile  gauze. 

In  addition  to  the  dangers  of  this  occurrence,  the  delays 
caused  by  refitting  another  bottle  were  very  annoying.  After 
the  third  accident  of  this  kind  had  occurred  I  began  to  experi- 
ment with  various  metallic  bottles,  and  after  a  number  of  trials 
I  finally  concluded  to  adopt  the  model  shown  in  Figs,  i  and  2. 
The  receptacle  consists  of  a  polished  copper  cylinder,  nickel- 
plated  on  its  outer  and  inner  surfaces,  measuring  20  cm.  (8 
inches)  in  circumference  and  14  cm.  (5|^  inches)  in  length.  The 
top  is  provided  with  a  metal  T-tube,  allowing  the  air  to  enter 
and  the  fluid  to  escape,  both  ends  of  the  T  being  provided  with 
stopcocks.  The  actual  capacity  of  the  cylinder  is  13  ounces 
(nearly  400  c.c).  but  only  lo  ounces  (300  +  c.c.)  of  fluid  are  used 
to  allow  sufficient  space  for  the  air  charge.     The  cylinder  has 


414  MATAS, 

been  tested  to  stand  147  pounds  of  internal  hydrostatic  press- 
ure per  square  inch,  and  when  the  attachments  are  screwed  on 
it  is  absolutely  water-tight  under  the  highest  pressure.  The 
fluid  is  introduced  into  the  receptacle  through  the  bottom, 
which  is  closed  by  a  brass  nickel-plated  cover,  made  to  screw 
tightly  over  a  rubber  washer  into  the  cylinder.  The  bottom  is 
also  provided  with  two  pinions,  which  favor  the  grip  of  the 
fingers  in  screwing  it  to  the  cylinder.  These  are  not  essential, 
however,  as  the  bottom  piece  screws  on  easily  to  the  cylinder. 
A  glass  water-gauge,  protected  by  a  graduated  metal  case,  is 
fixed  to  the  cylinder  to  allow  the  operator  or  the  assistants  to 
keep  account  of  the  amount  of  fluid  used  as  the  operation  pro- 
gresses. This  gauge  is  a  very  important  part  of  the  apparatus, 
and  can  be  easily  detached  for  aseptic  purposes.  The  pumping 
outfit  consists  of  a  small  bicycle  hand-pump,  the  smallest  made; 
it  is  13  cm.  (5^  inches)  in  length  and  7  cm.  (nearly  3  inches) 
in  circumference,  and  is  very  cheap  (costing  only  15  cents). 
This  is  attached  to  a  small  metallic  cylinder,  7^  cm.  (3  inches) 
in  circumference  by  5^  cm.  (2^  inches)  in  length,  which  is 
filled  with  sterile  absorbent  cotton,  and  is  used  as  a  filter  for  the 
air  injected  into  the  reservoir. 

After  the  sterilized  solution  has  been  placed  in  the  receptacle 
this  is  charged  with  air  until  marked  resistance  is  felt  in  driving 
the  piston,  when  the  attachments  to  the  filter  and  pump  are 
unscrewed,  and  the  apparatus  is  ready  for  infiltration.  The 
needles  used  for  injecting  are  of  various  sizes,  lengths,  and 
curves ;  eight  are  provided  with  the  outfit  varying  in  size  and 
calibre  from  a  fine  hypodermic  syringe  (for  intradermal  work) 
to  a  large  7  cm.  needle  (Dieulafoy,  No.  2),  which  is  used  when 
the  rapid  cedematization  of  large  areas  is  required.  The  rubber 
tubing  connecting  the  apparatus  to  the  injecting  needle  is  38 
cm.  (a  little  over  15  inches)  long,  to  give  the  necessary  freedom 
of  movement  to  the  operator  in  handling  the  needle.  The  rub- 
ber tubing  is  the  most  perishable  part  of  the  apparatus,  as  the 
rubber  is  easily  damaged  by  prolonged  and  repeated  steriliza- 
tion. As  this  tube  is  intended  to  convey  only  the  sterile  fluid 
it  is  unnecessary  to  subject  it  to  long  sterilization,  and  usually 


APPARATUS    FOR     INFILTRATION    ANESTHESIA.       415 

an  immersion  of  three  minutes  in  boiling  water,  followed  by  a 
bath  in  a  formalin  solution,  i  per  cent.,  suffices  to  make  it  per- 
fectly safe  from  the  aseptic  point  of  view,  without  seriously 
impairing  the  elastic  qualities  of  the  rubber. 

The  chief  advantages  claimed  for  this  apparatus  over  the  ordi- 
nary syringes  used  for  infiltration  anaesthesia  are:  (i)  That  it 
allows  the  operator  to  infiltrate  and  cedematize  large  areas 
rapidly,  continuously  or  interruptedly  without  the  delay  caused 
by  recharging  or  exchanging  syringes  ;  (2)  that  by  the  use  of 
long  needles  it  tends  to  diminish  the  traumatism  caused  by  fre- 
quent punctures  made  necessary  by  the  shorter  needles  used 
with  the  ordinary  quickly  exhausted  syringes. 

The  rapidity  with  which  the  solution  is  forced  into  the  tissues 
as  well  as  the  thoroughness  with  which  this  is  done  is  surpris- 
ing. In  addition  to  this  the  limited  number  of  punctures 
required  to  infiltrate  a  very  large  area,  sometimes  one  or  two 
punctures  being  sufficient  when  a  fine  7  cm.  needle  is  used, 
greatly  diminishes  the  traumatism  of  the  tissues  and  enor- 
mously expedites  the  work. 

The  contrast  between  this  method  and  the  older,  in  which 
the  ordinary  hand-syringes  of  small  capacity  are  used,  is  agree- 
ably apparent,  and  will  be  readily  appreciated  by  anyone  who 
has  been  operating  by  the  classical  methods.  Since  I  have 
adopted  the  present  method  I  have  obtained  far  more  satisfac- 
tory results  in  extensive  operations,  and  have  used  Schleich's 
weaker  No.  3  (i/ioo  of  i  per  cent.)  with  much  greater  success;  in 
fact,  I  have  learned  to  rely  on  infiltration  alone — z.  ^.,  depending 
chiefly  upon  the  physical  rather  than  the  chemical  effects  of  the 
solution  than  formerly.  The  solutions  used  in  my  practice  at 
present  are  1/5,  i/io,  1/20  and  i/ioo  of  eucain  B.,  dissolved  in 
8/10  of  I  per  cent.  sod.  chlorid.  solution  (Heinze),  sterilized  by 
boiling.  The  15  of  i  per  cent,  solution  is  used  for  the  intrader- 
mal injection — the  weaker  solution  for  the  subcutaneous  areas. 

The  solutions  are  injected  tepid  or  cold  into  the  tissues ;  after 
the  infiltration  is  completed  the  entire  field  is  covered  with  a 
sterile  ice-bag  for  three  or  five  minutes,  which,  by  refrigerating 
the  solution,  greatly  intensifies  the  anaesthetic  action. 


4l6        APPARATUS    FOR     INFILTRATION    ANSTHESIA. 

The  details  of  the  methods  and  their  applications,  according 
to  the  indications  furnished  by  the  special  tissues  involved  and 
the  pathological  conditions  encountered  in  the  tissues,  have 
been  detailed  in  the  contribution  referred  to  published  by  me 
(loc.  cit.,  Nov.  3,  1900).  Since  that  time  my  experience  has 
widened  very  much,  and  I  have  improved  constantly  in  the 
technique  as  my  experience  has  increased.  It  would  be  inter- 
esting to  describe  some  of  the  more  exceptional  cases  in  which 
the  possibilities  of  mas"sive  infiltration  have  been  tested,  especially 
in  the  major  surgery  of  the  face,  neck,  genito-urinary  apparatus, 
and  extremities,  but  my  purpose  on  this  occasion  is  simply  to 
describe  an  improved  apparatus,  which,  since  December,  1900, 
to  the  present  date  (May  7,  1901)  has  proved  a  most  valuable 
auxiliary  in  the  prosecution  of  my  anaesthetic  work. 

The  apparatus  has  been  manufactured  for  me  by  the  McDer- 
mott  Surgical  Company,  of  New  Orleans,  and  is  now  sold  by 
them  in  a  compact  wooden  case,  which,  in  addition  to  the  local 
infiltration  apparatus,  has  a  complete  outfit  for  spinal  cocainiza- 
tion,  ethyl  chloride  spray,  with  space  for  the  dry  eucain  B. 
and  cocaine  tablets  required  in  making  the  anaesthetizing  solu- 
tions. I  am  especially  indebted  to  the  manufacturers  and  to  my 
assistant,  Dr.  John  Smyth,  for  valuable  suggestions  and  other 
assistance  in  completing  the  working  details  of  the  apparatus. 

Since  this  article  has  been  written  I  have  read  a  contribution 
by  Dr.  Ludwig  Moszkowicz,  assistant  of  Professor  Gersuny, 
Vienna  {Cejitralblatt  f.  Chirurgie,  No.  19,  May  11,  1901),  in 
which  he  describes  a  glass  bottle  apparatus  for  Schleich  infil- 
tration anaesthesia. 

This  apparatus  is  practically  an  adaptation  of  the  Potain 
aspirator  apparatus,  and  is  in  every  essential  point  identical 
with  the  contrivance  described  and  illustrated  by  me  in  the 
Philadelphia  Medical  Journal  of  November  3,  1900.  I  am 
much  pleased  to  find  a  confirmation  of  my  ideas  and  results  in 
Dr.  Moszkowicz's  and  Professor  Gersuny's  clinics,  but  believe 
that  the  same  objections  which  led  me  to  abandon  the  glass 
bottles  for  a  metallic  reservoir  will  also  obtain  in  Vienna  after 
a  more  mature  experience. 


TWO    CASES    OF   VICIOUS    CIRCLE    AFTER 
GASTRO-ENTEROSTOMY. 


BY  THEODORE  A.  McGRAW,  M.D., 

DETROIT,  MICH. 


The  term  "  vicious  circle "  is  applied  by  the  Germans  to 
those  pathological  conditions  occurring  subsequent  to  gastro- 
enterostomies in  which  the  contents  of' the  stomach,  instead 
of  following  their  proper  course  through  the  efferent  portion 
of  the  jejunum  to  the  ileum,  pass  into  the  afferent  limb  of  the 
jejunum,  and  thence  into  the  duodenum.  If  unrelieved,  the 
bile  and  other  intestinal  secretions  and  the  ingesta  will,  after 
distending  the  duodenum  and  adjacent  jejunum  to  the  utmost, 
regurgitate  into  the  stomach  and,  if  not  vomited,  cause  great 
distention  and  pain,  and  hiccough,  and  finally  cause  death  by 
exhaustion.  L  had  practised  gastro-enterostomy  over  ten  years 
without  meeting  a  case  of  this  kind,  when  two  cases  in  quick 
succession  aroused  me  to  an  appreciation  of  a  danger  which  I 
had  come  to  regard  as  somewhat  chimerical.  I  published  a 
summary  of  one  of  these  cases  in  the  New  York  Medical 
Journal^  of  June  26,  1900,  in  an  article  entitled  ''Gastro- 
enterostomy by  the  Elastic  Ligature."  The  reason  for  its  pub- 
lication then  was  to  show  the  effect  of  the  elastic  ligature  as 
illustrated  by  a  post-mortem  specimen.  I  wish  now  to  publish 
it  in  more  detail  in  order  to  compare  its  history  with  that  of 
the  second  case,  which  followed  so  closely  on  its  heels.  In 
recording  both  cases  I  shall  omit,  as  far  as  possible,  all  such 
details  as  may  not  seem  relevant  to  my  purpose,  in  order  not 
to  weary  my  readers. 

Am  Surg  37 


4l8  MCGRAW, 

Case  I. — A  Canadian,  aged  thirty-one  years,  a  patient  of  Dr. 
Bryan,  of  Essex,  Ontario,  came  to  me  with  cancer  of  the  pylorus. 
His  family  history  was  bad.  One  sister  had  died  of  cancer  of  the 
stomach,  and  another  was  then  suffering  with  it.  His  disease  had  made 
rapid  progress.  He  had  noticed  it  first  in  June,  1900,  and  in  Novem- 
ber it  had  caused  nearly  complete  obstruction.  I  operated  on 
November  15,  1900,  and  made  a  gastro-enterostomy  by  means  of  the 
elastic  ligature.  A  transverse  incision  was  carried  from  the  median 
line,  3  cm.  above  the  navel,  10  cm.  to  the  left,  through  the  abdominal 
wall.  The  jejunum  was  drawn  up  in  front  of  the  colon,  turned  so  as 
to  bring  the  efferent  portion  to  the  right  of  and  over  the  afferent  por- 
tion, and  attached  by  the  elastic  ligature  to  the  posterior  wall  of  the 
fundus  of  the  stomach.  The  ligature  included  a  length  in  the 
stomach  wall  of  about  5  cm.  and  about  the  same  length  in  the  wall 
of  the  jejunum.  On  each  side  of  the  ligature  for  a  distance  of  6  or  7 
cm.  the  serous  coats  of  the  two  viscera  were  securely  fastened 
together  by  fine  silk  threads.  The  abdomen  was  closed,  and  a  high 
enema  of  one  ounce  of  brandy  and  two  pints  of  normal  saline  solu- 
tion was  administered  before  the  patient  awoke.  Throughout  the 
whole  course  of  his  subsequent  illness  the  kidneys  acted  normally, 
and  the  urinary  record  may,  therefore,  be  omitted. 

Noveynber  15th.  11. 10  a.m.,  operation.  1.30  p.m.,  hypodermic 
injection  of  digitalin,  gr.  i/ioo ;  strychniae  sulph.,  gr.  1/40.  2.40 
P.M.  Patient  conscious.  Temp.,  98.4°  F.  \  pulse,  90.  4  p.m.  Temp., 
98.4°;  pulse,  90.  Hypodermic  injection  of  digitalin,  gr.  i/ioo; 
strychniae  sulph.,  gr.  1/40.  8  p.m.  Nutritive  enema,  peptonized  milk, 
§vj ;  brandy,  .5J.  Pulse,  98.  Hypodermic  injection  as  before,  with 
addition  of  codeiae  sulph.,  gr.  1/4.  Temp.,  99. 4°.  11  p.m.  In  pain. 
Hypodermic  of  strychnige  sulph.,  gr,  1/40;  digitalin,  gr.  i/ioo;  mor- 
phiae  sulph.,  gr.  1/8, 

xdth.  2  A.M.  Temp.,  100.2°;  pulse,  116.  High  enema  of  one  pint 
normal  saline,  six  ounces  of  peptonized  milk,  and  one  ounce  of 
brandy.  Hypodermic  of  strychniae  and  digitalin  as  before.  5  a.m. 
Hypodermic  of  strychniae  sulph.,  gr.  i/ioo;  digitalin,  gr.  1/40. 
Temp.,  101°  ;  pulse,  100.  8  a.m.  Nutritive  enema,  peptonized  milk, 
gvj ;  brandy,  %.  Chipped  ice  in  mouth.  9  a.m.  Enema  passed 
from  bowels,  it  a.m.  Temp.,  101°;  pulse,  112.  Hypodermic  of 
strychniae  sulph.,  gr.  1/40;  digitalin,  gr.  i/ioo.  11.30  p.m.  Nutritive 
enema  with  ten  drops  of  laudanum.  Hypodermic  of  strychnia^  sulph., 
gr,   1/40;    digitalin,    gr.    i/ioo.     Temp.,   101°;    pulse,   108.     3    p.m. 


VICIOUS     CIRCLE    AFTER     G AST RO- ENT EROSTO M Y .       4I9 

Passed  enema  from  bowels.  4  p.m.  Temp.,  101°  ;  pulse,  104.  Chipped 
ice.  5.30  P.M.  Hypodermic  of  strychnisesulph.,  gr.  1/40;  digitalin,  gr. 
i/ioo.  6.40  P.M.  Nutritive  enema  as  before.  Temp.,  100.6°;  pulse, 
108.  8  P.M.  Hypodermic  of  strychniae  sulph.,  gr.  1/40;  digitalin, 
gr.  i/ioo.  II  P.M.  Hypodermic  of  strychniae  sulph.,  gr.  1/40;  digi- 
talin, gr.  i/ioo.  II  P.M.  High  enema  of  normal  saline,  Oj ;  pepton- 
ized milk,  5iv;  brandy,  5J. 

i-jth.  1. 15  A.M.  Temp.,  99.3°  ;  pulse,  102.  Hypodermic  of  strychniae 
sulph.,  gr.  1/40,  digitalin,  gr.  i/ioo.  4.30  a.m.  Passed  some  of  the 
enema  and  urinated  ;  had  rested  very  well  during  night.  7  a.m. 
Temp.,  99.4;  pulse,  100.  Hypodermic  of  strychniae  sulph.,  gr.  1/40; 
digitalin,  gr.  i/ioo.  Nutritive  enema,  peptonized  milk,  gvj  ;  brandy, 
§j.  II  a.m.  Passed  some  of  the  enema.  Temp.,  100.2°  ;  pulse,  120. 
I  P.M.  Nutritive  enema,  peptonized  milk,  gvj ;  brandy,  ,5J.  1.30 
p  M.  Temp.,  100.8°;  pulse,  112;  5  P.M.  Beef-broth  by  mouth,  3j. 
Temp.,  100.2°;  pulse,  132.  6.40  p.m.  Nutritive  enema  as  before. 
7  p.m.  Passed  portion  of  enema.  11.30  p.m.  Temp.,  99°;  pulse,  98. 
Beef-broth  by  mouth,  5J. 

18/-^.  I  a.m.  Nutritive  enema  with  tr.  opii.,  n\^x.  6  a.m.  Beef- 
broth,  5J.  Temp.,  99°;  pulse,  92.  7.50  a.m.  Beef-broth,  §j.  8.3o 
A.M.  Nutritive  enema  of  peptonized  milk,  §vj ;  brandy,  ^j ;  tr.  opii, 
ni^x.  9.20  A.M.  Enema  passed  from  bowels.  Temp.,  98.8°; 
pulse,  96.  Milk  by  mouth,  gij.  11  a.m.  Wound  dressed;  healing 
per  primam.  i  p.m.  Nutritive  enema  as  before.  3.30  p.m.  Enema 
passed  from  bowels.  4  p.m.  Temp.,  99.2° ;  pulse,  100.  Milk  by 
mouth,  3iij.  5.  p.m.  Milk  by  mouth,  3iij.  6  p.m.  Milk  by  mouth, 
.^iij.  7  P.M.  Milk  by  mouth,  5iij.  11.40  p.m.  Temp.,  98.4°;  pulse, 
92.     Nutritive  enema.     Milk  given  in  small  quantities  every  hour. 

\<)fh.  Temp.,  98.4°  ;  pulse,  96.  Milk  given  in  small  quantities  every 
hour.  8  A.M.  Chicken-broth  by  mouth,  |ij.  Milk  given  in  small 
quantities  every  hour.  10  a.m.  Beef-broth  by  mouth,  5ij.  Milk 
given  in  small  quantities  every  hour.  Bowels  moved.  Nutritive 
enema  and  some  fecal  matter.  5  p.m.  Milk  and  custard  by  mouth. 
Temp.,  99°;  pulse,  84.  7.45  p.m.  Milk,  ,^iv.  9  p.m.  Custard,  §j. 
10.30  p.m.  Milk,  3ij.     11.20  P.M.  Milk,  5ij. 

20th.  2  A.M.  Milk,  f  iij.  7  A.M.  Temp.,  98.3°  ;  pulse,  80.  4  p.m. 
Temp.,  98.4°;  pulse,  104.  5  p.m.  Milk-toast  and  gruel.  11  p.m. 
Patient  now  became  cold  and  clammy,  and  complained  of  severe 
abdominal  pain.     Heat  applied  to  abdomen  and  extremities. 

2ist.    I  a.m.  Pain  continues.     Codeiae  sulph.,  gr.  j  ;  spir.  frumenti, 


420  MC  GRAW, 

§j;  to  be  given  every  three  hours.  Patient  continued  anxious  and 
distressed  during  night.  7  A.M.  Temp.,  100°;  pulse,  120.  Milk, 
§ij.  9  A.M.  Bowels  moved  by  enema.  10  a.m.  I  saw  him  for  the 
first  time  after  his  pain  began.  I  found  the  upper  part  of  the  abdo- 
men swollen.  Patient  complained  of  nausea  and  pain.  Believing  the 
trouble  due  to  overfeeding  and  indigestion,  I  oidered  nitromuriatic 
acid,  pepsin,  and  brandy,  and  directed  more  moderation  in  feeding. 
Temp.,  92.4°;  pulse,  100.  12  M.  Beef-broth,  |j.  i  p.m.  Medicine. 
Chicken-broth,  3J.  4  P.M.  Milk,  §iij.  7  p.m.  Temp.,  99.2°;  pulse, 
116.  Easier.  10.30  p.m.  Great  pain  in  abdomen.  Suffers  from 
hiccough.     1 1. 1 5  P.M.     Milk,  gij. 

22d.  Patient  slept  little  during  the  night,  and  had  constant  hic- 
cough. Food  discontinued  during  night.  7  a.m.  Temp.,  99.3°; 
pulse,  96.  8  A.M.  Malted  milk,  giij.  10.30  a.m.  Beef-broth,  §ij. 
Abdomen  still  swollen.  Patient  in  considerable  distress.  3  p.m. 
Malted  milk,  5iij.  4  p.m.  Temp.,  99.4°  ;  pulse,  112.  Gruel,  strained, 
5ij.  Vomited  thick,  dark  yellow  fluid,  about  gvj.  All  food  by 
mouth  was  now  discontinued.  Patient  suffered  from  abdominal  pain 
and  hiccough.  7  p.m.  Temp.,  99.2°;  pulse,  108.  9  p.m.  Nutrient 
enema,  peptonized  milk,  gvj ;  brandy,  5J ;  tr.  opii,  n\,x.  This  was 
retained.     Morph.  sulph.,  gr.  1/8  by  hypodermic  injection. 

23^'.  3  a.m.  Nutrient  enema  as  before  ;  retained,  and  patient  rested 
well.  8.30  A.M.  Bowels  moved  by  simple  enema.  9  a.m.  Nutritive 
enema,  i  p.m.  Nutritive  enema.  3  p.m.  Strychnige  sulph.,  gr.  1/40 
by  hypodermic  injection.  Temp.,  99°  ;  pulse,  88.  4  p.m.  Temp., 
98.6°;  pulse,  88.  5  P.M.  Urinated  and  passed  enema.  7  p.m. 
Nutritive  enema.  Strychnise  sulph.,  gr.  1/40  by  hypodermic  injection. 
9  P.M.  Urinated  and  passed  enema. 

24M.  I  A.M.  Nutritive  enema.  3.20  a.m.  Urinated  and  passed 
enema.  During  the  night  the  patient  rested  fairly  well.  7  a.m.  Temp., 
97.3°;  pulse,  80.  Nutritive  enema.  11  a.m.  Evacuation  of  bowels. 
12  a.m.  Evacuation  of  bowels.  Clear  broth  by  mouth,  5ij.  i  p.m. 
Nutritive  enema.  4  P.M.  Temp.,  98.3°;  pulse,  108.  5  p.m.  Strained 
gruel,  gij.     7  P.M.   Nutritive  enema.     8.30  p.m.  Beef-tea,  giv. 

25///!.  I  A.M.  Nutritive  enema.  Patient  rested  very  well  during  the 
night,  though  troubled  with  occasional  hiccough.  8  a.m.  Fecal 
movement  after  simple  enema.  Sutures  removed.  Wound  healed 
by  first  intention.  12  M.  Cup  of  tea.  2  p.m.  Nutritive  enema.  5  p.m. 
Temp.,  98.4°;  pulse,  78.  11  p.m.  Malted  milk.  11.30  p.m.  Chicken- 
broth. 


VICIOUS    CIRCLE    AFTER    G ASTRO-ENTE ROSTO M Y .      42  I 

26M.  I  A.M.  Nutritive  enema.  Rested  well  all  night.  7  a.m.  Temp., 
98°;  pulse,  88.  8  a.m.  Nutritive  enema,  retained  one  hour.  12.45 
P.M.  Strained  beef-soup,  ^iij.  Patient  complained  of  severe  abdomi- 
nal pain.  I  P.M.  Clear  soup,  ^iij.  1.40  p.m.  Nutritive  enema.  2.30 
P.M.  Bowels  distended  in  upper  part,  great  pain.  Hypodermic  of 
morph.  sulph.,  gr.  1/6;  atropine  sulph.,  gr.  i/ioo.  4  P.M.  Temp., 
99.4°;  pulse,  98.  Pain  lessened.  5.30  p.m.  Beef-broth,  5iij.  7  p.m. 
Nutritive  enema.  9  p.m.  Malted  milk  by  mouth,  gij.  In  more  pain. 
9.45  P.M.  Hypodermic  of  morph.  sulph.,  gr.  1/6;  atrop.  sulph., 
gr.  i/roo. 

2'jth.  Patient  slept  well,  but  complains  again  of  pain.  7  a.m.  Temp., 
98.6° ;  pulse,  88.  Simple  enema  expelled  with  much  gas.  8  a.m. 
Nutritive  enema — retained.  9.30  a.m.  Egg-nog,  5ij.  11  a.m.  Com- 
plains of  pain.  Prescribed  morph.  sulph.,  gr.  1/32,  in  peppermint- 
water,  every  hour  until  relieved.  12  m.  Egg-nog,  sj.  2  p.m.  Nutritive 
enema — retained  fifteen  minutes.  2.30  p.m.  Chicken-broth,  ^ij.  7 
p.m.  Nutritive  enema — retained  one  hour.  Temp.,  99°;  pulse,  to8. 
8.30  P.M.  Vomited  about  5iv  of  brown  fluid.  Strychnise  sulph., 
1/50  by  hypodermic  injection.  9.15  p.m.  Nutritive  enema.  I  now 
gave  directions  for  an  operation  early  next  morning. 

28//^.  I  a.m.  Vomited  a  quantity  of  dark  colored  fluid.  Temp., 
97.4°;  pulse,  132.  Patient  slept  until  2.45,  when  he  awoke  feeling 
very  faint.  Hypodermic  of  strychniae  sulph.,  gr.  1/50.  3  a.m.  Nutri- 
tive enema.  Intense  pain  in  abdomen.  4.15  a.m.  Hypodermic  of 
strychniae  sulph.,  gr.  1/50.  Digitalin,  gr.  i/ioo.  Collapse  and  death 
at  4.45  A.M. 

Five  hours  after  death  I  made  a  post-mortem  examination,  which, 
for  certain  reasons,  had  to  be  very  hurried.  I  opened  the  wound  and 
examined  the  bowels.  I  have  to  regret  that  I  omitted,  in  my  haste, 
to  note  the  relative  positions  of  the  afferent  and  efferent  limbs  of  the 
jejunum.  I  found  the  afferent  portion,  the  duodenum  and  stomach, 
all  enormously  distended  with  fluid,  and  the  afferent  (wrongly  printed 
in  the  N.  Y.  Medical,  Journal  as  efferent)  tense.  I  had  not  allowed 
sufficient  length  to  that  portion  of  the  intestine,  and  it  made  a  decided 
traction  upon  the  stomach.  Removing  the  stomach,  with  the  adherent 
jejunum,  I  found  a  perfect  and  beautiful  anastomosis  with  an  orifice 
five  centimetres  long. 

I  will  reserve  comment  on  this  case  until  I  have  reported 
Case  II. 


422  MC  GRAW, 

Case  II. — Mr.  P.  L.,  aged  fifty-two  years,  has  been  ill  with  dyspeptic 
symptoms  several  years.  During  this  time  he  had  suffered  from 
eructations  of  gas,  distress  at  the  pit  of  the  stomach,  and  occasional 
vomiting.  This  had  gradually  increased  in  severity  until  September, 
1900,  when  the  vomiting  became  so  frequent  as  to  indicate  obstruc- 
tion. His  physician.  Dr.  Chapoton,  washed  the  stomach  out  fre- 
quently, with  only  temporary  relief.  Analysis  of  test  breakfasts,  made 
at  intervals,  showed  the  presence  of  hydrochloric  acid  in  large  pro- 
portion and  an  entire  absence  of  lactic  acid.  A  small  indentation 
could  be  felt  to  the  right  of  the  median  line  in  the  hypochondriac 
region,  which  changed  its  position  and  seemed  movable. 

The  diagnosis  of  Dr.  Chapoton,  in  which  I  concurred,  was  that  of  a 
benign  pyloric  tumor.  The  stomach  was  only  moderately  dilated. 
He  entered  St.  Mary's  Hospital  for  operation  on  January  9th,  but 
was  kept  under  observation  for  three  days,  during  which  every  effort 
was  made  by  nutritive  enemata  and  frequent  hypodermic  injections 
of  strychniae  sulph.  and  digitalin  to  increase  his  strength.  His 
stomach  was  washed  out  with  boric- acid  solutions.  His  temperature 
ranged  during  these  three  days  from  normal  to  102.2°  F.  His  highest 
point  was  attained  on  November  nth,  at  3  p.m.  His  temperature  on 
November  12th,  one  hour  before  operating,  was  100.2°  F.  His  urine 
was  normal,  and  continued  to  be  so  during  his  whole  illness.  On 
November  12th,  at  10  a.m.,  operation  after  usual  preparations. 
Incision  ten  centimetres  in  length,  beginning  about  three  centimetres 
above  the  navel  in  the  median  line,  and  carried  transversely  to  the 
left.  The  stomach  was  found  free  of  all  adhesions  and  only  a  very 
little  enlarged.  The  pylorus  was  the  seat  of  a  dense  tumor  about  as 
large  as  a  walnut.  There  were  no  infected  glands  that  I  could  feel. 
I  brought  the  jejunum  up  in  front  of  the  colon  and  joined  it  to  the 
posterior  wall  of  the  stomach  by  an  elastic  ligature  at  a  distance  of 
about  fifty  centimetres  from  the  duodenum.  The  operation  was  then 
completed,  two  pints  of  normal  saline  solution  with  one  ounce  of 
brandy  injected  high  up  in  the  colon,  and  the  patient  put  to  bed. 

January  12th.  5  p.m.,  resting  quietly.  Temp.,  100.4°  F.  6.15 
P.M.,  hypodermic  of  strychnige  sulph.,  gr.  1/60;  morphine  sulph., 
gr.  1/4;  digitalin,  gr.  i/ioo.  10  p.m.  Temp.,  99.6°  F. ;  pulse,  96. 
Troubled  with  hiccough.  12  p.m.  Hypodermic  of  strychnia:  sulph., 
gr.  1/60  ;  digitalin,  gr.  i/ioo. 

13M.  12,30  A.M.  Nutritive  enema  of  peptonized  milk,  5vj ;  brandy, 
§j.       Urination    painful    and    frequent.       425   a.m.    Temp.,    99.2°; 


VICIOUS    CIRCLE    AFTER    G A ST RO- ENT E ROSTO M Y .       423 

pulse,  94.  Hypodermic  of  strychniae  sulph.,  g.  1/60;  digitalin,  gr. 
i/ioo;  morph.  sulph.,  gr.  1/6.  Patient  slept  well  at  intervals,  but 
complained  of  sharp  abdominal  pain.  7  a.m.  Nutritive  enema — 
retained.  8.30  a.m.  Temp.,  99  2°  F.  ;  pulse,  94.  Hypodermic  of 
strychniae  and  digitalin  as  before.  11.30  a.m.  gxiv  urine  by  catheter, 
urotropin,  grs.  v;  salol,  grs.  xx,  to  be  given  every  six  hours  in 
nutritive  enema.  Temp.,  99.2°  F. ;  pulse,  94.  12.30  p.m.  Nutritive 
enema — retained.  Strychnise  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo. 
I  P.M.  Hypodermically.  5.40  p.m.  Passed  urine  with  great  pain. 
Temp.,  100  1/5°  F.  ;  pulse,  96.  Strychnise  sulph.,  gr.  1/60;  digitalin, 
gr.  i/ioo,  hypodermically.  7.35  p.m.  Temp.,  101.2°;  pulse,  118. 
Urinated,  ^ij.  Had  a  chill  lasting  fifteen  minutes.  Bowels  moved. 
7.45  p.m.  Morph.  sulph,  gr.  1/4,  hypodermically.  8  p.m.  Urinated; 
passed  gas  from  rectum.  8.50  p.m.  Very  restless ;  pulse,  124;  passed 
Sij  urine,  9  p.m.  Temp.,  103.4°  F.;  pulse,  128.  Urinated  again; 
very  restless,  but  sleeps  a  few  minutes  at  a  time.  Bowels  moved ; 
offensive  odor.  10.30  p.m.  Temp.,  104.2°  F.;  pulse,  130,  very 
weak.  Hypodermic  of  strychnine  sulph.,  gr.  1/40;  digitalin,  gr.  i/ioo. 
Foot  of  bed  elevated  and  normal  saline  Oj,  spir.  frumenti,  §j,  injected 
under  skin  of  both  axillae. 

i^th.  12.30  A.M.  Nutritive  enema  given,  but  soon  expelled.  Hypo- 
dermic of  strychniae,  gr.  1/40;  digitalin,  gr.  i/ioo.  1.30  a.m.  Temp., 
101.4°  F.;  pulse,  120.  Stool  of  black  and  offensive  liquid.  Urin- 
ated. Sleeps  at  intervals.  3  a.m.  gij  cold  water  by  mouth.  4.15 
A.M.  Temp.,  100.2°  F. ;  pulse,  114.  Hypodermic  of  strychniae 
sulph.,  gr.  1/40;  digitalin,  gr.  i/ioo;  5iv  cold  water  by  mouth. 
6.10  A.M.  Cold  water,  siv ;  has  rested  quietly.  7.30  a.m.  Temp., 
99.2°  F.;  pulse,  102.  Hypodermic  of  strychniae  sulph.,  gr.  1/40; 
digitalin,  gr.  i/ioo.  8.30  a.m.  Nutritive  enema  of  peptonized  milk, 
§vj ;  brandy,  .5J,  tr.  opii.  gtt.  xx,  retained.  10  a.m.  Wound 
dressed.  Healing  per  primam.  10.40  a.m.  Temp.,  98.4°;  pulse,  98. 
Glass  of  water  by  mouth.  11. 15  a.m.  Glass  of  water.  12.30  p.m. 
Temp.,  99°;  pulse,  100.  Hypodermic  of  strychniae  and  digitalin. 
1.30  P.M.  Beef-broth,  §j,  by  mouth.  2.15  p.m.  Nutritive  enema. 
Urinated.  3.15  p.m.  5]  of  hot  tea.  3.30  p.m.  Strychniae  sulph., 
gr.  1/60;  digitalin,  gr.  i/ioo,  by  hypodermic.  Urinated.  5.20  p.m. 
Passed  urine,  gxi.  Temp.,  99°;  pulse,  98.  6.15  p.m.  Chicken 
broth  5J.  Urinated.  Hypodermic  of  strychniae  sulph.,  gr.  1/60; 
digitalin,  gr.  i/ioo.  7  P.M.  Nutritive  enema,  retained.  Urinated; 
resting  quietly.     9  P.M.  Temp.,  99°  ;  pulse,  94.     Hot  tea,  5J.     Patient 


424  MC  GRAW, 

complains  of  pain  in  abdomen.  11.15P.M.  Hypodermic  of  strychniae 
sulph.,  gr.  1/60;  digitalin,  gr.  1/60;  morph.  sulph.,  gr.  1/8.  12  p.m. 
Temp.,  98.4°;  pulse,  90. 

15M.  I  A.M.  Nutritive  enema,  retained.  1.40  a.m.  5J,  chicken 
broth.  5.30  A.M.  Hypodermic  of  strychnise  sulph.,  gr.  1/40;  digi- 
talin, gr.  i/ioo.  Complains  of  great  abdominal  pain.  8.30  a.m. 
Temp,,  98.2°;  pulse,  102.  Liquid  peptonoids,  giij  by  mouth. 
Bowels  moved  freely  by  aid  of  simple  enema.  Urinated.  9.30  a.m. 
Hypodermic  of  strychnise  and  digitalin.  9.45  a.m.  Patient  vomited 
greenish  fluid.  11. 15  a.m.  Nutritive  enema.  11.30  a.m.  Slight  move- 
ment of  bowels.  Upper  part  of  bowels  swollen.  Patient  nauseated. 
12.15  P-^^'  Temp.,  98.4°;  pulse,  no.  Sleeping.  4  P.M.  Hypo- 
dermic strychniae  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo.  5  p.m. 
Temp.,  99.3°  F. ;  pulse,  112.  5.30  p.m.  Slight  movement  of  bowels, 
and  again  at  6.15.  6.20  p.m.  Nutritive  enema  of  peptonized  milk, 
5vj  ;  brandy,  5].  8  p.m.  Hypodermic  strychnise  sulph.,  gr.  1/60; 
digitalin,  i/ioo.  Bowels  moved  slightly.  Urinated.  Cold  water 
giv.  Complains  of  abdominal  pain.  Bowels  distended  above  navel. 
II. 15  p.m.  Morph.  sulph.,  gr.  1/4  by  hypodermic  injection.  12  p.m. 
Patient  vomited  dark  green  fluid.     Cold  water  5iv. 

i6f/i.  12.10  a.m.  Hypodermic  of  strychnine  sulph.,  gr.  1/60;  digi- 
talin, gr.  i/ioo;  temp.,  98.8°  F.;  pulse,  106.  Complains  of  pain. 
6.45  A.M.  Urinated.  Cold  water,  5iij.  Patient  had  slept  fairly  well 
during  night.  7.20  a.m.  Temp.,  98.2°;  pulse,  96.  Nutritive  enema. 
Hypodermic  of  strychnise  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo.  8.45 
a.m.  Vomited  dark  green  fluid.  10.50  a.m.  Vomited  dark  green 
fluid.  11.20  a.m.  Cold  water,  ^ij.  12  m.  Cold  water,  gij.  Taken 
to  operating-room. 

The  wound,  which  was  healing  by  first  intention,  was  reopened,  and 
from  its  inner  end  an  additional  incision  was  carried  directly  down- 
ward for  a  distance  of  eight  centimetres.  This  made  a  triangular 
flap,  which,  when  reflected,  exposed  the  stomach  and  all  of  the  intes- 
tines, which  lay  in  the  upper  half  of  the  abdominal  cavity  to  the  left 
of  the  median  line.  I  found  revealed  a  curious  condition  of  things. 
When  operating  I  had,  as  usual,  on  joining  the  intestine  to  the 
stomach,  turned  the  intestine  around  so  as  to  make  its  course  run 
from  left  to  right.  The  afferent  portion  was  then  on  the  left  side  of 
the  body,  the  eff'erent,  lying  over  it  on  the  right  side.  I  now  found 
the  position  reversed.  The  eff'erent  limb  was  on  the  left  and  the 
afferent  limb  on  the  right.     To  accomplish  this  change  the  stomach 


VICIOUS     CIRCLE    AFTER    G ASTRO- ENT E ROSTO M Y .      425 

had  been  partly  twisted  on  its  axis.  The  stomach  was  contracted  and 
contained  very  Jiitle  fluid.  The  efferent  limb  of  the  jejunum  was 
contracted  and  empty.  The  duodenum  and  adjacent  portion  of  the 
jejunum,  which  by  the  way  was  fully  fifty  centimetres  in  length,  were 
enormously  distended.  I  do  not,  indeed,  remember  to  have  ever  met 
with  the  small  intestine  so  greatly  enlarged.  I  made  a  small  incision 
and  evacuated  a  large  quantity  of  green  fluid  in  which  bile  was 
evidently  mixed  with  the  food  he  had  taken. 

The  afferent  and  efferent  limbs  of  the  jejunum  were  now  joined  by 
means  of  a  Murphy  button  about  fifteen  centimetres  from  the  stomach, 
and  the  abdomen  closed. 

16th.  1.20  P.M.  Patient  conscious.  Hypodermic  of  strychniaesulph., 
gr.  1/60;  digitalin,  gr.  i/ioo.  2.30  p.m.  Temp.,  100°  F. ;  pulse,  108; 
resting  quietly.  3.15  p.m.  Involuntary  stool.  Eructation  of  gas.  4.20 
P.M.  Temp.,  102.2°  F. ;  pulse,  126.  Urinated  involuntarily.  Com- 
plains of  pain  in  abdomen.  Eructations  of  gas.  5.30  p.m.  Hypo- 
dermic strychnine  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo;  temp., 
101.4°  F.;  pulse,  116.  6.30  p.m.  Temp.,  100.6°  F. ;  pulse,  116. 
Nutritive  enemata.  Cold  water,  giv,  by  mouth.  8.30  p.m.  Temp., 
100.2°  F.;  pulse,  116.  Hypodermic,  strychnise  sulph.,  gr.  1/60.  Cold 
water,  .^iv,  by  mouth.  Digitalin,  gr.  i/ioo.  9.30  p.m.  Temp., 
100.2°  F, ;  pulse,  114.  Cold  water,  giij.  Eructations  of  gas.  Vom- 
ited green  fluid.  Complains  of  abdominal  pain.  11  p.m.  Urinated 
voluntarily,  gvj.  Cold  water,  giv,  by  mouth.  11.30  p.m.  Strychnise 
sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo,  by  hypodermic  injection. 
Patient  fell  asleep. 

I'jth.  12.30  a.m.  Temp.,  100.2°  F.;  pulse,  108.  Cold  water,  gij ; 
nutritive  enemata,  retained,  i  a.m.  Restless.  5iij  cold  water.  2.30 
a.m.  Hypodermic  of  strychnise  sulph.,  gr.  1/60  j  digitalin,  gr.  i/ioo. 
4.45  a.m.  Has  rested  well  and  slept  since  2.30.  Temp.,  99.2°; 
pulse,  100.  Cold  water,  ^ij.  Complains  of  abdominal  pain.  5.30 
A.M.  Hypodermic  of  strychnise  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo. 
Urinated.  8.30  a.m.  Temp.,  99.4°;  pulse,  100.  Slept  two  hours. 
Cold  water,  giij.  Nutritive  enema,  retained.  9  a.m.  Vomited  dark 
green  fluid.  Resting  quietly.  10  a.m.  Vomited  gij  dark  green  fluid. 
10.35  A.M.  Temp.,  90.2°;  pulse,  106.  12.30  p.m.  Hypodermic  of 
strychnise  sulph.,  gr.  1/60;  digitalin,  gr.  i.ioo.  Cold  water,  sij. 
I  P.M.  Nutritive  enema.  Patient  slept  an  hour.  3.15  p.m.  Urinated. 
Cold  water,  5ij.  4  P.M.  Temp.,  90.4°;  pulse,  102.  Hypodermic 
strychnise  sulph,    gr.   1/60;    digitalin,   gr.   i/ioo.      Cold  water,  giij. 


426  MC  GRAW, 

6.15  P.M.  Eructation  of  gas.  Urinated.  Bowels  washed  out  with 
simple  enema.  7  p.m.  Temp.,  99.2° ;  pulse,  98.  Nutritive  enema 
retained.  Cold  water,  giv.  Resting  quietly.  8.30  p.m.  Strychnise 
sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo,  by  hypodermic.  8.55  p.m.  Glass 
of  water.  Eructation  of  gas.  11  p.m.  Has  slept  two  hours.  Much  pain 
in  abdomen.     Eructations  of  gas.      12  p.m.  Temp.,  99°;    pulse,  100. 

18//^.  12.30  A.  M.  Hypodermic  of  strychniae  sulph.,  gr.  1/60  ;  digi- 
talin, gr.  i/ioo;  morph.  sulph.,  gr.  1/4.  i  a.m.  Nutritive  enema. 
Patient  slept  two  hours.  Awoke  with  hiccough.  4.30  a.  M.  Temp., 
99°;  pulse,  100;  hypodermic  of  strychnise  sulph.,  gr.  1/60;  digitalin, 
gr.  i/ioo.  Glass  of  water.  7  a.m.  Has  slept  two  hours.  Temp., 
98.8°;  pulse,  94.  Glass  of  water,  3iij.  Malted  milk.  8.10  a.m. 
Nutritive  enema,  retained.  Hypodermic  of  strychnise  and  digitalin. 
10  A.M.  Eructation  of  gas.  giv  malted  milk.  Hiccoughs.  11  a.m. 
Temp,  99°;  pulse,  90.  5J  malted  milk.  1.25  p.m.  Nutritive  enema, 
retained.  5J  malted  milk.  Glass  of  water.  Troubled  much  with 
hiccough.  2.30  P.M.  Urinated.  Stool,  gj  malted  milk.  3  p.m. 
Malted  milk  sj.  Slept  one  hour.  5  p.m.  Temp.,  100.2°  F.;  pulse, 
96.  Malted  milk  §j.  Hiccoughs  troublesome.  8  p.m.  Hypodermic, 
strychnia  and  digitalin.  Malted  milk,  ^j.  9  p.m.  Temp.,  100.2°; 
pulse,  88.     Nutritive  enema.      11.30  p.m.  gj  malted  milk.    Hiccoughs. 

igth.  1.45  a.m.  Unable  to  sleep  by  reason  of  hiccough.  Hypo- 
dermic of  morph.  sulph.,  gr.  1/6.  3.30  a.m.  Slept  since  1.45  a.m. 
Hypodermic  of  strychnise  and  digitalin.  6  a.m.  Nutritive  enema. 
Has  taken  much  water  during  night.  Suffers  still  from  hiccough. 
9.35  A.M.  Hiccough  continues.  Wound  dressed.  Slight  superficial 
suppuration.  Acid  hydrocyan.  dilut.,  3J ;  aq,  menth.  piperit.,  5iij, 
a  teaspoonful  every  hour  until  relieved.  1.30  a.m.  Cup  of  tea.  Hic- 
cough still  continues.  12.45  ^•^^-  Hypodermic,  strychnise  and  digi- 
talin. Hot  tea,  gij.  1.45  p.m.  Nutritive  enema.  Hiccoughs  at 
intervals.  2.30  p.m.  Vomited  greenish  fluid.  3.30  p.m.  Vomited 
greenish  fluid.  Hiccough  continues.  6.30  p.m.  gij  hot  tea.  7  p.m. 
Temp.,  100.6°;  pulse,  100.  Has  rested  well  since  4  o'clock.  7.30 
P.M.  Hiccough,  but  not  so  bad.  9  p.m.  Nutritive  enema.  Hypo- 
dermic of  strychnise  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo;  morph. 
sulph.,  gr.  1/8. 

20th.  12.30  a.m.  Temp.,  100.2°;  pulse,  106.  Hypodermic  of 
strychnise  and  digitalin.  Hot  tea,  p;ij.  Complains  of  abdominal 
pain.  Abdomen  soft ;  not  tender  or  distended.  4.45  a.m.  Nutritive 
enema.     Hot    tea,   5ij.      8  a.m.    Slept  well.       No   hiccoughs.     Stool 


VICIOUS    CIRCLE    AFTER    CAST RO- ENTEROSTOMY.       427 

after  simple  enema.  10  a.m.  Hot  tea,  5!]  Wound  dressed.  11  a.m. 
Egg-nog,  5ij.  11.35  ^•^^-  Egg-nog,  gij.  12.10  p.m.  Strained  soup, 
gij.  2  P.M.  Nutritive  enema.  2.10  p.m.  §ij  egg-nog.  3  p.m.  ^ij 
egg-nog.  Free  movement  of  bowels.  3.30  p.m.  Temp.,  101.2°  F.; 
pulse,  106.  §ij  milk  and  lime  water.  Eructations  of  gas.  6.30  p.m. 
3J,  milk  and  lime  water.  8.45  p.m.  Temp.,  100.4°;  pulse,  106. 
Vomited  green  fluid.  9  p.m.  3J  milk  and  lime  water.  Urinated. 
9  20  P.M.  Nutritive  enema.  Hypodermic  of  strychnige  and  digitalin. 
9.30  P.M.  Vomited  green  fluid  mixed  with  milk.  11.30  p.m.  Patient 
restless  and  in  pain.     Morph.  sulph.,  gr.  1/4. 

2IJ-/.  Morph.  sulph.,  gr.  1/8,  hypodermic.  2.15  a.m.  Hot  tea,  §j. 
6  A.M.  Free  movement  of  bowels.  Temp.,  100.2°;  pulse,  104. 
Hot  tea,  5j.  7  A.M.  Temp.,  100.2°;  pulse,  108.  Had  slept  at 
intervals,  but  had  complained  of  much  pain.  Hypodermic  injection 
ofstrychniae  and  digitalin.  Hot  tea,  §j.  9  A.M.  Has  slept  since  7 
o'clock.  9  A.M.  Wound  dressed.  11-35  ^•^^-  Temp.,  100.4°; 
pulse,  98.  Slept  since  9  a.m.  Brandy  and  water,  §j.  Patient  feels 
weak.  12  A.M.  Brandy  and  water,  3J.  Urinated.  12.45  p.m.  Brandy 
and  water,  3J.  1.20  p.m.  Temp.,  101.2°;  pulse,  112.  Nutritive 
enema.  Hypodermic  of  strychnise  sulph.,  gr.  1/60;  digitalin,  gr. 
t/ioo.  Egg-nog,  sij.  2.30  p.m.  Brandy,  giv.  3  p.m.  Egg-nog, 
3j.  4.10  P.M.  Egg-nog,  5ij-  4-3°  P-M.  Temp.,  101.6°;  pulse, 
104.  Hypodermic  of  strychnine  and  digitalin.  5  p.m.  gij  mutton 
broth.  5.30  P.M.  Brandy,  ^iv.  6.30  p.m.  giij  albumin.  7  p.m. 
giv  brandy.  7.45  p.m.  gij  egg-nog.  8.30  p.m.  3iij  white  of  egg. 
9  P.M.  Temp.,  101.6°;  pulse,  104.  Brandy,  |j.  Nutritive  enema 
retained.     11  p.m.  Egg-nog,  gij.     Urinated. 

22^.  2.30  A.M.  Complains  of  pain  in  abdomen.  White  of  egg,  3ij. 
Hypodermic  of  strychniae  and  digitalin  with  one-sixth  gram  of 
morphia  sulph.  4.45  a.m.  Slight  evacuation  of  bowels.  5.15  a.m. 
Nutritive  enema.  Brandy,  jij.  Slept  well  during  night.  7.45  a.m. 
Temp.,  99.4°  F.;  pulse,  94.  Brandy,  ^ij.  9  a.m.  Bowels  moved 
by  simple  enema.  Egg-nog,  ^ij.  Wound  dressed  and  sutures  re- 
moved. 10  A.M.  Brandy,  gij.  10.35  a.m.  Strained  gruel,  gij.  11 
A.M.  Egg-nog,  siij.  12.35  p.m.  ^iv  white  of  egg.  i  p.m.  Mutton 
broth,  sij.  1.30  p.m.  Egg-nog,  3iij.  1.45  p.m.  Nutritive  enema. 
2.20  p.m.  Brandy  and  water,  gij.  3  p.m.  Cup  of  tea.  3.30  p.m. 
Brandy,  ^ij.  4.40  p.m.  Slept  3/4  hour.  Strained  gruel,  3ij.  6  p.m. 
Egg-nog,  3ij,  and  at  6.35  brandy,  gij.  7  p.m.  Temp.,  100.6°; 
pulse,   I02.      8.15  P.M.    Brandy,    gij.     8.45  p.m.    Beer,  ^iv.      9  p.m. 


428  MC  GRAW, 

Nutritive  enema.  Hypodermic  strychniae  sulph.,  gr.  1/60  ;  digitalin, 
gr.  i/ioo.  10  P.M.  Urinated  and  bowels  moved  freely.  10.15  ^•^' 
Beer,  3iv.  11.40  p.m.  Temp.,  102.6°:  pulse,  120.  Egg-nog,  gij. 
Patient  very  weak. 

23^/.  1. 15  A.M.  Temp.,  103.2°  ;  pulse,  124.  Hypodermic  strychnige 
sulph.,  gr.  1/40;  digitalin,  gr.  i/ioo;  brandy,  ^ij.  4  A.M.  Temp., 
102°;  pulse,  118.  Nutritive  enema.  5  a.m.  Hypodermic  injection 
strychniae  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo.  Slept  at  intervals, 
but  very  restless  and  weak.  7  a.m.  Temp.,  101.4°;  pulse,  108. 
Urinated.  Evacuation  of  bowels.  Mutton  broth,  .^ij.  8.30  a.m. 
Hypodermic  of  strychniae  sulph.,  gr.  1/60;  digitalin,  gr.  i/ioo. 
10.20  A.M.  Temp.,  100.2°  ;  pulse,  106.  Cup  of  tea.  11  a.m.  Chicken 
broth,  siv.  Resting  quietly.  12.10  p.m.  Egg-nog,  ^iij.  Very 
hungry.  1.15  p.m.  Beefsteak,  3J,  cut  fine,  and  tea.  2  p.m.  Temp., 
100.4°;  pulse,  114.  2.45  P.M.  Egg-nog,  giij.  3.10  p.m.  Brandy 
and  water,  3ij.  4  p.m.  Temp.,  100.4°;  pulse,  no.  5  p.m.  Cup  of 
tea.  5.45  P.M.  Brandy  and  water,  gij.  9  p.m.  Egg-nog,  giij.  9.30 
P.M.  Temp.,  100.4°;  pulse,  no.  11.45  ^•^^-  Has  slept  two  hours. 
Brandy  and  water,  ^ij. 

24/A.  2.30  A.M.  Temp.,  101.4°;  pulse,  112.  Cup  of  tea.  5  a.m. 
Egg-nog.  8.30  a.m.  Temp.,  99.2°;  pulse,  94.  Had  rested  well  and 
slept  since  two  o'clock.  10.30  a.m.  Egg-nog.  Dressing  removed  and 
remainder  of  stitches  removed.  Temp.,  99.6°;  pulse,  96.  11-15 
a.m.  Small  piece  of  beefsteak  with  toast  and  coffee.  12.15  P-^^- 
Brandy  and  water.  4.45  p.m.  Urinated  and  had  stool,  dark  in  color 
and  constipated.  5  p.m.  Oatmeal  porridge.  Egg,  toast,  and  tea. 
6.15  P.M.  Temp.,  100.2°;  pulse,  102.  8.30  p.m.  Egg-nog.  9.30 
p.m.  Cup  of  tea. 

25//^.  4  A.M.  Beefsteak,  milk-toast,  coffee.  Patient  had  slept  well 
all  night.  Temp.,  99.4°;  pulse,  100.  9  A.M.  Oatmeal  porridge, 
egg,  toast,  and  coffee,  n  a.m.  Egg-nog.  12.30  p.m.  Soup,  chicken, 
bread,  tea,  and  pudding.     5.30  p.m.   Beefsteak,  milk-toast,  tea. 

I  will  omit  the  detailed  account  of  his  convalescence  and  will  give 
in  short  the  remainder  of  the  history.  From  now  on  he  was  allowed 
to  eat  according  to  his  desire.  His  temperature  fell  to  normal  and  he 
continued  in  comfort  until  February  4th.  On  January  29th  he  was 
allowed  to  sit  up  for  the  first  time.  On  January  31st  he  began  to 
walk.  He  had  no  complaints  to  make  except  of  numerous  places  on 
the  thighs  which  had  been  the  seat  of  small  abscesses  as  the  result  of 
hypodermic  injections.     On  February  4th  he  passed  the  button.     At 


VICIOUS    CIRCLE    AFTER    G A ST RO- ENTEROSTOMY.      429 

four  o'clock  on  that  day  he  had  a  chill  with  fever;  temp.,  101°; 
pulse,  no.  At  8  P.M.  Temp.,  103.6°;  pulse,  158.  A  second 
heavy  chill.  8.30  p.m.  Temp.,  104,4°;  pulse,  148.  9  p.m.  Vom- 
ited his  dinner.  His  temperature  then  fell  to  normal  and  remained 
so  until  February  9th,  when,  without  apparent  cause,  he  had  a  chill 
with  a  temperature  of  102.2°  F.  The  cause  of  these  chills  was 
obscure.     He  left  the  hospital  on  February  12th,  feeling  well. 

On  March  ist  he  walked  into  my  office,  apparently  well,  and  com- 
plaining only  of  weakness.  He  had  had  no  more  fever  and  showed 
no  evidences  of  indigestion  or  obstruction.  If  we  examine  these  two 
cases  critically  we  will  find  marked  differences  in  the  symptoms  and 
course  of  their  trouble.  In  order  to  make  the  contrast  plainer  I  will 
summarize  the  two  records. 

Case  I.  began  on  the  evening  of  November  17th — fifty-three 
hours  after  the  completion  of  the  operation — to  take  nourish- 
ment by  the  mouth.  During  the  three  days  ending  November 
20th,  5  P.M.,  he  had  taken  fluids  by  the  mouth  aggregating 
approximately  three  pints  in  bulk.  At  1 1  p.m.,  November 
20th,  he  was  seized  with  severe  abdominal  pain,  the  upper  part 
of  the  abdomen  was  found  swollen,  and  he  became  clammy  and 
cold.  He  had  been  so  comfortable  during  the  three  days  of 
mouth-feeding  that  I  did  not  think,  as  yet,  of  serious  trouble, 
and  did  not  stop  giving  nutriment  by  mouth  until  November 
22d,  when,  for  the  first  time,  he  vomited  a  quantity  of  green, 
bitter  fluid.  He  began  again  at  noon,  November  23d,  to  take 
small  quantities  of  food  by  mouth,  and,  except  for  an  occasional 
hiccough,  was  comparatively  comfortable  until  noon  of  Novem- 
ber 26th,  when  he  began  again  to  complain  of  abdominal  pain 
and  distention  and  troublesome  hiccough.  His  pulse  on  the 
morning  of  November  27th  was  88,  and  of  good  volume;  his 
temperature,  98.3°.  At  8.30  P.M.,  and  again  on  November 
28,  at  I  A.M.,  he  vomited,  and  then  collapsed  and  died. 

Case  II.,  operated  on  January  12th,  began  to  take  water  by 
mouth  at  3  a.m.  January  14th,  and  at  1.30  p.m.,  of  the  same  day, 
small  quantities  of  nourishing  liquids.  He  had  taken,  in  all, 
less  than  a  pint  of  liquids — chiefly  water — when  on  January 
15th,  at  9.45  A.M.,  he  vomited  a  green,  bitter  fluid.     He  had 


430  MC  GRAW, 

complained  previously  of  abdominal  pain  and  distention.  He 
vomited  again  at  midnight,  and  on  January  i6th  at  8.45  A.M. 
and  10.50  A.M.  At  12  o'clock  he  was  operated  on  for  the  second 
time. 

In  Case  I.  the  post-mortem  revealed  an  empty  condition  of 
the  efferent  jejunum  and  an  enormously  distended  stomach, 
afferent  jejunum  and  duodenum.  The  afferent  jejunum  was  tense 
and  evidently  too  short  to  allow  free  motion.  I  must  regret  that 
it  did  not  occur  to  me  before  handling  the  intestines  to  note 
their  position  in  siUi. 

In  Case  II.  the  abdominal  section  showed  the  duodenum  and 
adjacent  jejunum  vastly  distended;  indeed,  I  do  not  think  that 
I  have  ever  seen  a  larger  small  intestine.  The  stomach  was 
small,  nearly  empty,  and  peculiarly  twisted,  as  I  have  described. 

In  the  first  case  the  patient  vomited  only  once  until  the  night 
of  the  final  collapse,  when  he  vomited  twice.  He  did  not  show 
any  signs  of  distress  at  all  until  after  three  days  of  mouth-feed- 
ing, whereas  the  second  patient  began  almost  immediately  to 
complain  of  pain,  and  in  less  than  thirty-one  hours  after  his  first 
mouthful  of  water  vomited  bile.  This  bilious  vomit  may  be 
regarded  as  the  first  symptom  of  a  completed  anastomosis,  and 
is  of  importance,  as  it  is  the  first  index  obtained  of  the  length  of 
time  required  for  the  elastic  ligature  to  accomplish  its  work  in 
the  human  subject.  It  occurred  seventy  hours  after  the  com- 
pletion of  the  operation.  How  long  before  the  vomiting  the 
anastomosis  had  been  completed  is,  of  course,  uncertain. 

The  absence  of  vomiting  in  the  first  case  deceived  me  in  diag- 
nosis, as  it  did  not  seem  possible  that  so  dangerous  a  condition 
could  exist  without  more  irritability  of  the  stomach. 

It  is  only  recently  that  I  found  the  explanation  of  this  in  a 
remarkable  article  in  the  Archives  fur  klinische  Chirurgie,  by 
Dr.  George  Kelling,  of  Dresden.  I  will  digress  here  a  moment 
to  express  my  admiration  for  the  scientific  accuracy  of  a  work 
which  has  been  to  me  a  great  source  of  information.  I  do  not 
think  that  anyone  who  seeks  to  become  an  expert  in  gastro- 
enterostomy can  afford  to  neglect  its  perusal.  The  articles  of 
Dr.  Kelling  are  published  in  the  first  two  numbers  of  the  sixty- 


VICIOUS    CIRCLE    AFTER    G AST RO- ENTE ROSTO M Y .       43  1 

second  volume  of  the  Archives,  year  1900.  According  to  Kell- 
ing,  Hirsch,  in  1892,  and  V.  Mering,  in  1897,  had  announced 
that  the  filling  of  the  duodenum  inhibited  the  contractions  of  the 
stomach.  During  the  process  of  digestion  the  food  passes  out 
of  the  stomach  in  an  interrupted  series.  As  soon  as  the  duo- 
denum becomes  filled,  the  gastric  contractions  cease  until  it 
becomes  empty,  when  they  again  force  the  ingesta  onward. 
Kelling  confirmed  the  observations  and  experimented  with  ref- 
erence to  their  bearing  on  the  question  of  gastro-enterostomy. 
He  found  that  when  the  jejunum  in  a  dog  was  cut  in  two  near 
the  duodenum,  its  upper  end  sewed  up,  and  its  lower  end  joined 
to  the  stomach  by  an  anastomosis,  the  dog  would  die,  however 
well  fed.  The  food  passing  into  the  duodenum  through  the 
pylorus  would  fill  and  distend  the  duodenum,  which,  in  this  way, 
had  become  a  blind  pouch,  and  the  inhibitory  action  of  the  dis- 
tended duodenum  would  prevent  the  stomach  from  discharging 
its  contents  into  the  open  end  of  the  jejunum,  and  the  dog  would 
die  of  starvation.  I  shall  not  take  time  and  space  to  relate  all 
the  varied  experiments  which  served  to  confirm  Kelling  in  his 
views ;  it  is  enough  to  say  that  it  seems  proven  that  the  disten- 
tion of  the  duodenum  will  exert  a  reflex  inhibitory  influence  on 
the  stomach  which  may  prevent  the  success  of  gastro-enteros- 
tomy. That  this  inhibitory  action  may  not  be  sufficiently  strong 
to  produce  this  result  in  all  cases  is  proven  by  my  second  case, 
in  which  there  was  frequent  vomiting,  and  nearly  total  evacua- 
tion of  the  contents  of  the  stomach,  even  though  the  duodenum 
was  distended  to  its  utmost  capacity.  It  is  possible  that  the 
vomiting  in  this  case  may  have  been  produced  solely  by  the 
action  of  the  diaphragm  and  abdominal  muscles.  It  was,  how- 
ever, without  question,  this  duodenal  reflex  which  enabled  my 
first  patient  to  live  for  days  with  a  distended  and  irritated  stomach 
without  vomiting.  It  is  curious  that  when  the  irritation  becomes 
stronger  than  the  inhibition,  and  the  stomach  does  contract,  it  is 
with  a  reversed  peristalsis  that  causes  vomiting,  but  does  not  pro- 
pel the  ingesta  into  the  open  channel  of  the  attached  jejunum. 
This  happened  to  Kelling's  dogs.  They  vomited  bile,  but  died 
of  inanition,  although  the  way  was  open  for  the  passage  of  food 


432  MC  GRAW, 

into  the  small  intestine.  The  importance  of  these  observations 
on  all  questions  connected  with  operations  on  the  stomach  can- 
not be  over-estimated.  It  is  a  si7ie  qua  Jton  for  the  success  of  a 
gastro-enterostomy  that  the  stomach  should  be  able  to  exert  a 
normal  contractility.  Kelling  has  demonstrated  its  necessity. 
The  hydrostatic  conditions  of  the  stomach  are  such  that  gravity 
plays  no  part  whatever  in  the  propulsion  of  food  through  an 
aperture  into  the  intestine.  The  stomach  floats  on  the  intestines 
as  on  a  cushion  ;  it  and  its  contents  and  the  underlying  intes- 
tines have  nearly  the  same  specific  gravity,  a  fact  which,  in  this 
connection,  is  not  altered  by  the  gas  which  makes  certain  coils 
lighter  than  others. 

If  we  suppose  the  stomach  after  a  gastro-enterostomy  filled 
with  food,  the  gas  existing  in  it  and  in  the  connecting  coil  of  the 
jejunum  would  rise  to  the  top  or  become  mingled  with  the  con- 
tained fluids.  There  could  be  no  force,  then,  to  push  these  fluids 
from  the  stomach  into  the  intestine,  except  the  muscular  con- 
traction of  the  stomach  itself,  for  gravity  could  play  no  part, 
when  all  parts  concerned  are  of  equal  gravity.  The  muscular 
contractions  of  the  diaphragm  and  abdominal  wall  act  alike  on 
all  of  the  contents  of  the  abdomen,  and,  therefore,  have  no  influ- 
ence in  the  propulsion  of  food.  Whether,  then,  the  contents  of 
the  stomach  would  be  forced  into  the  intestine  or  the  contents 
of  the  intestine  into  the  stomach  would  depend  upon  the  relative 
power  exerted  by  the  two  viscera. 

If  the  intestine  contracted  the  more  vigorously,  the  most  per- 
fect anastomosis  could  be  of  no  avail,  and  the  only  relief  which 
the  stomach  could  attain  must  be  by  vomiting.  It  is  not  neces- 
sary for  the  contractile  power  to  be  entirely  overcome  to  make 
a  failure  of  a  gastro-enterostomy.  It  needs  only  to  be  weakened 
to  a  degree  that  makes  it  less  than  that  of  the  intestine  into 
which  it  must  empty.  It  is  not  enough,  therefore,  to  secure  a 
good  exit  for  ingesta  into  the  efferent  limb  of  the  jejunum,  for 
it  is  equally  important  to  prevent  the  collection  of  fluids  in  the 
afferent  portion.  In  no  other  way  can  we  secure  to  the  stomach 
the  ability  to  exercise  its  full  contractile  power,  and,  in  the  light 
of  our  present  knowledge,  the    avoidance  of  "  vicious  circles" 


VICIOUS    CIRCLE    AFTER    G ASTRO- ENTE ROSTO M Y.      433 

would  seem  to  depend  upon  the  solution  of  this  problem.  At 
present  I  can  see  no  other  choice  than  to  combine  with  every 
gastro-enterostomy  an  entero-enterostomy  between  the  two 
limbs  of  the  jejunum.  The  duodenum  could  then  discharge  its 
contents  into  the  efferent  limb  of  the  jejunum,  and  the  inhibition 
exercised  on  the  stomach  by  its  distention  be  relieved. 

The  relative  positions  of  the  afferent  and  efferent  portions  of 
the  jejunum,  as  discovered  in  the  second  operation  on  Case  II., 
are  deserving  of  special  study.  At  the  second  operation  I  had,  as 
is  customary,  turned  the  coil  of  intestine  so  as  to  bring  the  direc- 
tion of  its  peristaltic  movement  to  correspond  with  that  of  the 
stomach.  At  the  close  of  the  operation  the  afferent  branch  was 
on  the  left  and  the  efferent  on  the  right.  On  opening  the  abdo- 
men again  I  found  the  position  reversed.  The  afferent  limb  lay 
to  the  right  of  the  efferent,  and  both  were  parallel  to  the  long 
axis  of  the  body.  To  accomplish  this,  the  posterior  wall  of  the 
stomach  had  been  given  a  peculiar  twist  and  been  bent  upon 
itself.  Whether  this  was  the  cause  of  the  ''vicious  circle"  or 
was  the  effect  of  vomiting  or  other  disturbance  cannot  be  decided. 
It  might  possibly  have  been  the  result  of  the  weight  of  the  long 
afferent  limb,  when  filled  with  fluid,  causing  it  to  sink  among 
the  lighter  coils  containing  gas.  I  cannot  avoid  the  suspicion 
that  this  twist  was  the  cause  of  all  the  trouble,  and  the  question 
arises  in  my  mind  whether  the  same  condition  did  not  occur  in 
the  first  case,  in  which  the  unfortunate  shortness,  and  conse- 
quent tension,  of  the  afferent  limb  would  be  an  efficient  cause  of 
disturbance.  It  is  evident  that  such  a  twist,  however  produced, 
could  not  take  place  without  obstructing  the  course  of  one  or 
the  other  intestinal  channels. 

It  is  a  serious  question  whether  the  "  vicious  circle  "  may  not 
actually  be  caused,  in  some  instances,  by  the  very  manoeuvre 
which  was  meant  to  prevent  it.  I  am  not  aware  that  any 
numerous  observations  are  recorded  of  the  positions  ultimately 
assumed  by  the  two  limbs  of  the  jejunum  months  after  the  opera- 
tion. It  would  be  of  great  interest  to  know  if  the  loop  formed 
by  turning  the  intestine  during  the  operation  persisted  as  a  loop, 
or  whether  it  disappeared  in  time  as  the  afferent  branch  ranged 

Am  Surg  28 


434  ^^  GRAW, 

itself  in  its  more  natural  position  on  the  right  of  its  neighbor. 
This  is  certain,  that  in  a  few  cases  these  loops  have  acted  as  traps 
in  which  the  intestine  has  become  entangled.  In  the  sixty- 
second  volume  of  the  Ai'chives  fur  klinische  Cliiriirgie^  Peter- 
sen records  three  cases  in  which  this  accident  occurred  in 
the  Heidelberg  Clinic  alone.  How  often  it  may  have  occurred 
elsewhere  is  not  recorded.  This  practice  of  turning  the  intes- 
tine to  make  its  peristaltic  direction  correspond  to  that  of  the 
stomach  originated  with  Lucke  and  Rockewitz,  in  1887,  and 
was  published  in  that  same  unlucky  article  in  which  they  advised 
the  profession  to  unite  the  stomach  with  the  highest  available 
coil  of  small  intestine,  without  taking  the  time  and  trouble  to 
trace  out  its  position,  an  advice  which  cost  many  lives. 

The  suggestion  as  to  peristaltic  direction  was  adopted  with 
enthusiasm  by  the  Germans,  and  accepted  by  all  surgeons  as  an 
article  of  faith.  It  may  be  well  to  ask  whether  this  dogma  has 
any  assured  basis.  Is  there  any  practical  utility  in  making  the 
movement  of  the  ingesta  pass  in  a  straight  line  through  stomach 
and  intestine?  If  so,  is  it  possible,  under  the  abnormal  condi- 
tions which  exist  with  an  obstructed  pylorus,  to  secure  with 
certainty  any  correspondence  between  the  movements  of  the 
stomach  and  those  of  the  intestine?  It  must  be  remembered 
that  the  turning  of  the  intestine  adds  materially  to  the  difficul- 
ties of  the  operation  and  to  its  subsequent  dangers.  Indeed, 
Petersen  advises,  in  order  to  avoid  the  dangers  of  intestinal 
entanglement,  such  as  occurred  in  the  three  cases  recorded  from 
the  Heidelberg  Clinic,  that  the  surgeon  make  an  incision  large 
enough  to  view  the  whole  field  of  operation,  and  that  he  make 
the  afferent  limb  of  the  jejunum  as  short  as  possible.  The  first 
of  these  directions  would  lengthen  the  operation  considerably, 
and,  in  the  exhausted  patients  upon  whom  we  have  to  operate, 
materially  add  to  its  danger;  the  second,  if  closely  followed, 
would  lead  to  such  disaster  as  I  experienced  in  my  first  case, 
where  the  afferent  jejunum  was  made  too  short  and  caused,  I 
think,  the  death  of  my  patient.  It  is  curious  that  it  does  not 
seem  to  have  occurred  to  the  surgeons  who  have  met  with  dis- 
aster from  this  practice  of  turning  the  intestine  that  the  practice 


VICIOUS    CIRCLE    AFTER     G A ST R O- E N T E R O ST O M Y .       435 

itself  is  useless  and  vicious,  and  ought  to  be  abandoned.  When 
there  is  pyloric  stenosis  the  contraction  of  the  stomach,  unable 
to  cause  an  outward  movement  of  the  ingesta,  can  only  add  to 
the  tension  of  the  gastric  walls  and  thus  produce  a  pressure  equal 
in  all  directions.  The  force  will  then,  inevitably,  expend  itself 
in  the  direction  of  the  least  resistance,  and  the  food  will  be 
ejected  through  any  open  channel,  regardless  of  the  situation  of 
its  orifice  or  course  of  the  current.  When  once  in  the  intestine 
it  will  be  shoved  along  by  the  muscular  contractions  of  that 
viscus  after  the  normal  manner.  If  the  way  is  open  into  one  por- 
tion of  the  intestine,  and  closed  into  the  other,  it  must  pass  into 
the  open  door.  If  there  is  a  bar  across  one  passage  and  not 
across  the  other,  that  bar  will  control  the  event.  How  absurd, 
therefore,  it  is  to  complicate  the  operation  by  an  attempt  to  pro- 
duce a  movement  in  a  given  direction,  when  the  direction  of  the 
movement  has  no  material  influence  on  the  issue.  The  causes 
of  the  "  vicious  circles  "  are  conditions,  either  mechanical  or 
physiological,  which  prevent  the  ingesta  from  following  the 
desired  course  into  the  efferent  portion  of  the  jejunum.  The 
physiological  conditions  are  such  as  affect  the  motility  of  the 
stomach.  Thus  extreme  tenuity  of  the  stomach  walls,  with  great 
loss  of  muscular  power,  would  contraindicate  a  gastro-enteros- 
tomy,  as  there  would  not  be  force  enough  to  overcome  the 
resistance  offered  by  the  intestine  to  the  entrance  of  food.  So, 
too,  the  inhibition  of  gastric  movement  by  a  full  duodenum  may 
operate  to  produce  the  dreaded  vicious  circle.  As  regards  the 
mechanical  obstacles  to  success,  it  would  not  be  possible  to  pro- 
vide against  all  of  the  flexions  and  entanglements  which  might 
occur  after  abdominal  operations,  but  one  general  rule  may 
lessen  the  chances  of  their  occurrence,  namely,  the  rule  of 
avoiding,  as  far  as  possible,  all  complicated  methods  which  leave 
the  intestines  in  unusual  and  strained  positions. 

Kelling  advises  that  a  small  opening  be  made,  as  a  large  one 
is  more  conducive  to  the  formation  of  a  spur.  While  he  is 
undoubtedly  right  in  his  theory  as  to  the  greater  liability  of  the 
large  aperture  to  spur  formation,  I  cannot  agree  with  him  that 
the  remedy  lies  in  making  a  smaller  opening  of  communication. 


436  MC  GRAW, 

Small  openings  are  liable  to  contractions  and  closure.  In  a 
recent  case  of  Dr.  S.  J.  Mixter's,  of  Boston,  this  contraction  had 
reduced  an  aperture  which  had  been  occupied  by  a  large  Murphy- 
button  at  the  time  of  operation  to  a  hole  which  would  not  admit 
a  lead-pencil.  The  operation  had  been  performed  for  the  relief 
of  a  gastric  ulcer,  and  as  the  contraction  took  place  the  old  symp- 
toms recurred  and  a  new  operation — this  time  by  an  elastic 
ligature — was  made  necessary  for  its  relief  These  cases  are  not 
infrequent,  and  would  attract  more  attention  if  it  were  not  that 
the  majority  of  these  operations  are  made  for  cancerous  troubles, 
which  carry  off  the  patients  before  the  fistulae  have  so  nearly 
closed  as  to  cause  distress. 

Even  in  cancer,  where  the  life  is  prolonged  for  more  than  a 
year,  a  large  aperture  can,  alone,  prevent  the  recurrence  of  symp- 
toms of  obstruction,  while  in  cases  of  benign  stenosis  the  for- 
mation of  an  orifice  so  small  as  to  endanger  the  permanent  result 
of  the  operation  would  be  a  grave  error.  The  one  method  of 
operating  by  which  the  dangers  of  spur  formation  may  be 
avoided,  and  yet  a  large  orifice  made,  is  that  of  combining  an 
enterostomy  with  a  gastro-enterostomy.  This  method,  as  is 
well  known,  has  been  advocated  by  many  surgeons,  and  if  it  has 
not  found  universal  acceptance,  it  is  because  surgeons  have  feared 
to  prolong  the  operations  on  patients  so  exhausted  as  those 
which  we  have  to  deal  with  in  this  line  of  work.  If,  in  this 
double  operation,  we  use  Murphy  buttons  we  have  two  large 
foreign  bodies  which  have  to  find  their  way  through  the  intes- 
tines. If,  on  the  other  hand,  we  use  sutures,  the  operation  is  very 
much  prolonged.  In  either  case  we  double  the  danger  of  sepsis 
by  making  two  anastomoses  by  means  of  open  intestinal  wounds. 
It  is  here  that  I  wish  to  urge  upon  the  profession  a  careful  com- 
parison of  these  open-wound  methods  with  that  of  the  elastic 
ligature  which  I  introduced  in  1891.  Whether  we  use  the  Mur- 
phy button  or  the  suture,  we  must  open  the  viscera  and  expose 
the  patient  to  a  certain  danger  of  sepsis.  The  elastic  ligature 
passed  through  the  walls  of  the  intestines  permits  of  no  escape 
of  fluids  or  gases  and  reduces  that  danger  to  nothing.  In 
rapidity  of  performance    the  elastic   ligature  is  far  beyond  all 


VICIOUS    CIRCLE    AFTER    G AST RO-ENTE ROSTO M Y.       437 

other  methods.  It  can  be  done  as  quickly  as  one  can  pass  a 
needle  and  tie  a  knot.  Unlike  the  suture,  it  can  leave  no 
unguarded  point  for  the  escape  of  intestinal  contents,  and  it 
holds  the  viscera  firmly  together  until  it  cuts  through  the 
opposing  tissues.  It  is  not  like  the  Murphy  button,  a  compli- 
cated mechanism,  liable  to  fail  us  at  a  critical  moment.  It  leaves 
no  foreign  body  behind  which  has  to  be  forced  through  the 
intestine  and  which  often  passes  into  the  wrong  channel.  It  cuts 
its  way  through  the  tissues  with  absolute  precision,  if  properly 
applied,  and  at  a  period,  certainly  less  than  seventy  hours,  prob- 
ably less  than  fifty,  makes  a  perfectly  clean  anastomosis  with 
even  edges  and  a  minimum  of  scar.  It  has  the  enormous  advan- 
tage of  enabling  the  surgeon,  without  loss  of  time,  to  make  the 
orifice  of  communication  of  any  desirable  length.  After  a  large 
experience  with  this  method  on  dogs,  and  a  small  one,  li^nited 
as  yet  to  six  cases,  on  men,  I  can  see  no  valid  argument  that 
can  be  alleged  against  its  use  except  the  time  which  must  elapse 
before  the  patient  can  be  allowed  to  take  food  by  the  mouth. 
The  question  here  arises  whether  in  operations  by  other  methods 
patients  are  much  better  off  in  this  respect.  The  vast  majority  of 
them  suffer  for  twenty-four  hours,  or  more,  with  a  nausea  which 
forbids  the  taking  of  any  food  whatever  into  the  stomach  for  a 
varying  period  after  abdominal  operations.  The  motility  of  the 
viscera  is  impaired,  and  it  is  often  two  or  three  days,  even  after 
operations  which  take  a  perfectly  aseptic  course,  before  a  rattling 
in  the  bowels  and  the  passage  of  gas  denote  the  recovery  by 
the  intestines  of  their  power  of  motion. 

It  is.  of  course,  useless  to  put  food  of  any  kind  into  the 
stomach  when  it  is  not  in  condition  to  force  it  through  into 
the  jejunum,  for  the  stomach  itself  will  not  even  absorb  water. 

But  not  only  is  the  motility  of  the  viscera  temporarily  sus- 
pended by  surgical  operations,  but  their  power  of  absorption 
also  is  impaired,  and  if  medicines  are  given  by  mouth  shortly 
after  the  operation  they  may  not  manifest  their  effects  for  many 
hours  after  their  exhibition.  It  is  reasonable  to  suppose  that  the 
stomach  and  jejunum  which  have  been  directly  injured  by  a 
surgical  procedure  will  suffer  more  from  these  impairments  of 


438  MC  GRAW, 

function  than  the  large  intestine,  which  is  only  indirectly  affected, 
and  it  is  a  question  whether  the  patient,  after  a  gastro-enteros- 
tomy  by  any  method  whatever,  will  not  for  the  first  forty-eight 
hours  get  more  nourishment  from  nutritive  enemata  than  from 
mouth-feeding.  We  may  assume  that  these  conditions  would 
vary  widely  in  different  individuals.  I  am  not  aware  of  any 
experiments  or  observations  bearing  upon  the  effect  of  intesti- 
nal operations  on  the  motility  and  power  of  absorption  of  the 
various  viscera,  and  it  is  impossible  to  make  absolute  statements 
regarding  them  until  we  have  exact  scientific  data.  I  feel  war- 
ranted, however,  in  saying  this  much,  that  patients  operated  on 
by  the  elastic  ligature  thrive  very  well  on  nutritive  enemata  for 
the  fifty  hours  which  must  elapse  before  they  can  take  fluids  by 
the  mouth.  In  the  use  of  the  elastic  ligature  for  gastro-enter- 
ostomy,  simple  as  it  is,  the  surgeon  must  inform  himself  of  the 
proper  technique.  He  must,  first  of  all,  choose  a  proper  rubber 
cord.  Rubber  threads  or  weak  rubber  bands  will  not  do;  they 
may,  from  sheer  lack  of  strength,  fail  to  accomplish  their  pur- 
pose. For  the  same  reason  the  ligature  must  be  made  of  the 
very  best  rubber.  There  are  various  grades  of  rubber  in  the 
market. 

The  ligature  which  I  first  used,  in  1891,  was  a  cord  two 
millimetres  in  diameter.  I  put  it  aside  for  nine  years,  and  then 
when  I  took  up  the  operation  again  I  found  it  as  strong  and  good 
as  ever.  When  I  had  used  it  up  I  could  get  no  more,  as,  for 
some  unknown  reason,  it  was  no  longer  manufactured.  I  tried 
in  my  last  operation  a  smaller  cord,  which  in  that  case  answered 
the  purpose,  but  the  rubber  proved  to  be  of  poor  quality,  and  a 
few  days  afterward,  as  I  was  examining  it,  it  broke  in  pieces  in 
my  hands.  At  my  request.  Nelson,  Baker  &  Co..  of  Detroit, 
had  some  manufactured  of  proper  size  from  a  first  grade  rubber. 
These  ligatures  will  stretch  to  six  times  their  length  without 
breaking  or  suffering  any  impairment  of  their  elasticity.  They 
can  be  obtained,  if  desired,  from  this  firm.  The  best  needles  to 
use  with  these  ligatures  are  common  large,  darning  needles. 
They  are  round,  and  have  large  eyes,  into  which  the  ligature, 
when  shaved  thin  at  the  end,  can  easily  be  coaxed.       When 


VICIOUS    CIRCLE    AFTER    G AST RO- ENTEROSTO M Y.       439 

operating  by  this  method  the  wall  of  the  stomach  or  intestine 
should  be  grasped  in  a  fold  and  the  needle  thrust  through  the 
base  of  the  fold.  By  making  traction  on  the  ligature  as  the 
needle  is  pulled  through  the  cord  is  thinned  and  readily  follows 
its  guide.  Whatever  length  of  tissue  is  desired  for  division 
should  be  included  in  one  ligature.  When  the  ligature  is  passed 
through  both  viscera  it  should  be  drawn  tight  with  one  turn  of 
the  knot.  A  silk  thread,  previously  placed  in  position,  should 
now  be  tied  tightly  around  the  knot,  and  the  process  repeated 
with  the  second  turn  of  the  knot.  Lembert  stitches  may  be  so 
placed,  outside  and  inside,  as  to  hide  the  knots  from  view. 

I  am  confident  that  a  proper  ligature  placed  in  the  proper 
way  and  drawn  sufficiently  tight  will  never  fail  in  its  object. 

It  has  not  been  my  purpose  in  this  paper  to  present  an 
exhaustive  study  of  all  the  questions  which  arise  in  regard 
to  the  causes,  symptoms  and  treatment  of  the  '^  vicious  circle." 
I  offer  it  merely  as  a  clinical  study  from  which  I  have  sought  to 
draw  certain  practical  conclusions  which  will  serve,  perhaps,  for 
our  present  guidance,  and  be  valid  until  new  studies  and  new 
methods  make  it  desirable  to  change  our  practice.  These  con- 
clusions may  be  stated  as  follows  : 

1.  The  "vicious  circle"  may  occur  whenever  the  duodenum 
becomes  permanently  distended,  even  though  the  efferent  limb 
of  the  jejunum  offers  an  open  passage  to  the  ingesta.  In  all 
operations  of  this  kind,  therefore,  entero-enterostomy  should  be 
added  to  the  gastro-enterostomy  in  order  that  the  duodenum 
may  discharge  its  contents  into  the  efferent  portion  of  the 
jejunum. 

2.  It  may  also  occur  from  obstruction  due  to  spurs,  twists, 
bends  and  other  entanglements  of  the  intestines.  As  such  acci- 
dents may  arise  from  a  too  short  afferent  limb  of  the  jejunum, 
the  anastomosis  should  always  be  made  at  such  a  distance  from 
the  duodenum  as  would  make  trouble  from  this  cause  impossi- 
ble. The  practice  of  turning  the  bowel  around  in  order  to  make 
its  peristaltic  movements  correspond  with  those  of  the  stomach 
has  no  practical  advantage  whatever  in  cases  of  pyloric  stenosis, 
but,  on  the  contrary,  complicates  the  operation  and  tends  to 


440      VICIOUS    CIRCLE    AFTER     G A STRO- ENTEROSTO M Y, 

form  a  trap  in  which  the  intestine  may  become  entangled.  It 
may,  beside,  drag  the  wall  of  the  stomach  into  a  fold  which 
may  obstruct  the  opening  into  the  bowel.  This  method  of  join- 
ing the  viscera  should  be  altogether  discarded. 

3.  As  the  orifices  of  communication  may,  if  made  too  small, 
contract  and  become  obliterated,  the  opening  should  be  made  at 
least  five  centimetres  in  length.  The  effects  of  any  resulting 
spur  formation  will  be  obviated  by  the  entero-enterostomy. 

4.  The  safest  and  best  method  of  operating  is  that  by  the 
elastic  ligature. 


FlC.   2. 


Showing  abnormal  position  of  left  leg  in  sitting  posture. 


Fig.  3. 


Showing  abnormal  position  of  left  leg  and  prominence  ot  condyles  of  femur 
in  popliteal  space. 


Fig.  4. 


Showing  erect  posture  assumed  by  child.     The  right  hip  and  knee  are  flexed; 
the  left  limb  rests  on  condyles  of  the  femur. 


Fig.  5. 


Showing  lordosis  of  spine  caused  by  eiect  posture 


ANTERIOR  DISLOCATION  OF  THE  TIBIA  TREATED 
BY  ARTHROTOMY. 


By  JOHN  B.  ROBERTS,  M.D., 

PHILADELPHIA. 


A  LITTLE  girl,  aged  five  years,  born  after  a  hard  labor,  was 
brought  to  me  for  deformity  of  the  left  knee  by  Dr.  F.  S.  Nevling. 
I  found  that  the  tibia  was  displaced  forward  on  the  femur,  so  that  when 
the  child  lay  upon  her  back  the  tibia  extended  upward,  making  an 
angle  with  the  plane  of  the  bed  of  about  50°  or  60°.  The  small  patella 
could  be  felt  in  the  hollow  above  the  head  of  the  tibia.  The  condyles 
of  the  femur,  with  the  popliteal  artery  beating  between  them,  could  be 
felt  at  the  posterior  part  of  the  joint  close  to  the  surface  of  the  limb. 
The  child  had  learned  to  stand  on  both  legs  by  bending  the  spine  in 
the  lumbar  region,  so  that  there  was  a  marked  lordosis.  The  abdomen 
was  very  prominent,  and  the  costal  cartilages  of  the  ribs  were  thrust 
forward  in  such  a  manner  as  to  deform  the  chest.  The  girl's  head 
was  large  and  suggested  intellectual  deficiency.  The  mother,  how- 
ever, stated  that  she  was  as  bright  as  the  other  children,  and  had 
learned  to  talk  before  the  end  of  the  first  year.  A  skiagraph  was  taken 
and  showed  the  deformity  to  be  that  suspected — namely,  anterior  dis- 
placement of  the  tibia.  The  mother  says  that  the  labor  at  the  time 
of  the  child's  birth  was  a  severe  one,  and  that  the  presentation  was  a 
breech. 

On  March  22,  1901,  I  operated  under  ether  for  the  reduction  of  the 
dislocation.  A  large  horseshoe  incision  was  made  across  the  front  of 
the  knee  so  as  to  turn  up  a  large  flap.  The  ligament  of  the  patella 
was  divided  by  the  angular  incision,  which  is  often  used  in  lengthen- 
ing the  tendon  of  Achilles.  The  lateral  ligaments  of  the  joint  were 
divided  almost,  though  not  quite,  completely.  The  dislocation  was 
then  easily  reduced.  It  was  found  impossible  to  unite  the  ends 
of  the  ligament  of  the  patella,  though  a  third  of  an  inch  had  been 


442  ROBERTS, 

gained  by  the  manner  of  making  the  angular  incision  through  it. 
It  therefore  became  necessary  to  lengthen  the  four-headed  muscle 
attached  to  the  upper  portion  of  the  patella.  This  was  done  by 
exposing  the  muscle  through  a  longitudinal  incision  carried  upward 
on  the  front  of  the  thigh  from  the  original  horseshoe  incision.  The 
lower  end  of  the  muscle  was  dissected  free  from  the  surrounding 
tissues,  and  a  cut  made  across  it  from  the  inner  side  of  the  muscle  to 
about  the  middle.  This  allowed  the  ligament  of  the  patella  to  be 
drawn  together  perhaps  half  an  inch  more. 

Strong  chromicized  catgut  sutures,  four  or  five  in  number,  were 
passed  through  the  tendon  of  the  quadriceps  and  the  lower  piece  of 
the  ligament  of  the  patella  and  the  tissues  in  front  of  the  tibia.  Three 
of  these  sutures  went  through  the  tendon  of  the  muscle  above  the 
patella,  so  that  there  would  be  less  danger  of  the  great  tension  tearing 
them  out.  By  means  of  these  sutures  the  divided  ligament  of  the 
patella  was  brought  nearly  into  apposition,  while  the  tibia  was  kept 
slightly  flexed  on  the  femur.  The  external  wounds  were  sutured  and 
a  catgut  drain  left  in  the  outer  side  of  the  wound.  The  leg  was  then 
enveloped  in  an  aseptic  gauze  dressing  and  fixed  by  means  of  a 
gypsum  splint.  On  the  24th  the  temperature  of  the  child  was  high; 
the  gypsum  splint  was  then  removed,  the  catgut  drain  withdrawn,  a  few 
stitches  cut,  and  the  joint  irrigated  with  warm  sterile  salt  solution. 
The  next  day  the  inner  side  of  the  wound  and  the  upper  extremity  of 
the  cut  over  the  patella  were  opened,  because  of  the  fear  of  infection, 
which  was  suspected  to  be  the  cause  of  the  rise  in  temperature.  Irri- 
gation of  the  wound  with  sterile  salt  solution  was  begun. 

It  subsequently  became  necessary  to  lay  open  practically  the 
whole  wound  and  put  a  drainage-tube  through  beneath  the  patella. 
The  cause  of  the  infection  was  not  clear;  but  from  this  time  the  case 
was  treated  by  frequent  irrigations  with  corrosive  chloride  solution, 
and  subsequently  with  formaldehyde  solution.  The  wound  slowly 
closed,  and  the  child  was  sent  to  her  home  in  the  country,  at  the  end 
of  a  number  of  weeks,  with  a  straight  limb,  which,  however,  was 
greatly  restricted  in  motion  at  the  knee-joint.  It  is  probable  that 
under  massage  and  careful  passive  motion  of  the  joint  a  considerable 
degree  of  mobility  may  be  obtained.  The  desire  of  the  parent  to 
take  the  child  home  prevented  further  careful  supervision  of  the  treat- 
ment. There  was  a  tendency,  at  the  time  I  last  saw  the  child,  to  mod- 
erate external  deviation  of  the  tibia,  producing  a  condition  a  little  like 
knock  knee.     I  have  advised  the  wearing  of  a  brace  on  the  leg  and 


ANTERIOR     DISLOCATION    OF    TIBIA.  443 

the  use  of  massage.  The  skiagraph  and  photographs  taken  before 
the  operation  show  the  deformity  and  the  peculiar  attitudes  assumed 
by  the  child  in  the  endeavor  to  use  the  deformed  limb  in  walking.  I 
believe  that  under  careful  orthopedic  treatment  the  spinal  curvature 
due  to  the  abnormal  posture  of  the  patient  necessitated  by  the  dislo- 
cated knee  could  be  greatly  diminished.  It  is  to  be  feared  that  she 
will  be  unable  to  obtain  this  sort  of  surgical  treatment  in  her  home, 
which  is  distant  from  large  hospitals. 


GIANT  SACROCOCCYGEAL  TUMORS. 

An  Account  of  One  which   Pursued  an  Atrophic  Course. 


By  CHARLES  A.  POWERS,  M.D. 

DENVER. 


In  October,  1897,  there  came  under  my  observation,  through  the 
courtesy  of  Dr.  P.  V.  Carlin,  a  male  child,  aged  three  months,  who 
presented  an  unusual  growth  in  the  coccygeal  region.  The  tumor  was 
congenital,  and  at  birth  was  said  to  have  been  practically  of  the  pro- 
portional size  and  shape  which  it  had  when  I  saw  it,  and  to  have  pre- 
sented the  same  general  characteristics.  The  child  was  mature  at 
birth,  at  which  time  the  parents  were  told  that  it  would  probably  die. 
The  only  attention  which  the  mass  received  was  ordinary  cleanliness. 
The  child  thrived,  and  at  three  months  of  age  was  quite  as  strong  and 
as  well  nourished  as  babies  of  that  age  usually  are.    It  had  not  been  ill. 

Examination  of  the  child  when  first  seen  revealed  a  very  large 
growth,  occupying  the  sacrococcygeal  region,  extending  laterally  to 
the  buttocks  and  forward  in  front  of  the  anus.  The  growth  en- 
croached upon  the  left  buttock  rather  more  than  upon  the  right, 
reaching  well  to  the  gluteal  fold  on  the  left  side.  It  was  irregularly 
ball-shaped ;  the  entire  mass  was  as  large  as  the  head  of  a  child  six 
years  old.  The  tumor  measured  seventeen  inches  in  circumference. 
The  general  consistency  was  soft.  Below  and  in  front  it  was  markedly 
cystic  and  fluctuating,  while  above  and  laterally  it  was  firm,  and  in 
places  nodular.  The  firmer  portion  seemed  attached  to  deep  struc- 
tures, and  these  more  solid  parts  were  thrown  into  large,  irregular 
folds,  with  deep  creases  between  them.  The  skin  over  the  tumor  was 
normal  above  and  at  the  sides,  but  very  thin  and  of  a  bluish-red  over 
the  cystic  parts.  Large  veins  crossed  the  latter  portions.  The  skin 
was  freely  movable  over  the  fluid  portion  of  the  tumor,  but  tightly 
attached  in  the  crevices  above  mentioned.  The  cystic  portions  swayed 
with  the  movements  of  the  child.     Palpation  of  this  gave  the  impres- 


GIANT    SACROCOCCYGEAL    TUMORS.  445 

sion  of  one  or  more  large  cysts  and  many  small  ones,  with  here  and 
there  firm  portions  of  tissue.  Deep  palpation  failed  to  reveal  a  gap 
in  the  bony  structures.  Digital  examination  of  the  rectum  showed 
nothing  abnormal.  The  bowels  had  been  regular  and  the  movements 
natural.  There  had  been  no  abnormality  of  micturition.  When  the 
child  cried  the  upper  lateral  parts  of  the  tumor  were  moved  by  the 
gluteal  muscles,  but  the  tension  of  the  mass  itself  was  not  changed. 
There  was  neither  paralysis  nor  anaesthesia  of  the  lower  extremities. 
The  size,  shape  and  location  of  the  tumor  are  very  well  shown  in  Figs. 
I  and  2. 

Removal  of  the  mass  was  not  advised,  as  the  tumor  was  too  large  and 
the  baby  too  young.  Aspiration  of  the  fluid  contents  was  suggested, 
but  the  parents  did  not  take  kindly  to  the  thought,  and  it  was  not 
urged. 

The  mother  was  asked  to  keep  it  very  clean ;  to  wash  it  with  dilute 
alcohol  and  dust  it  with  a  simple  dusting  powder,  protecting  it  well  with 
soft  clothing.     She  gave  it  the  best  of  care.  • 

Three  months  later  the  tumor  was  in  about  the  same  condition ; 
there  had  been  no  appreciable  change.  Six  months  after  this,  or  when 
the  child  was  about  one  year  old,  the  fluid  portions  of  the  tumor  seemed 
to  be  less  prominent.  The  tumor  itself  had  rather  less  of  a  ball-shape. 
It  was  beginning  to  get  flat. 

The  child  was  seen  at  intervals  of  two  or  three  months.  The  tumor 
underwent  progressive  contraction  ;  the  skin  over  it  never  broke;  it 
was  never  ulcerated.  The  boy  had  the  usual  diseases  of  childhood  : 
measles,  whooping-cough,  diphtheria,  etc.,  but  his  physician  said 
that  he  came  through  them  all  without  accident.  He  waxed  strong 
and  hearty.  "He  is  the  strongest  of  my  six  children,"  said  the 
mother. 

Figs.  3,  4,  5,  and  6  show  the  condition  in  March,  1901,  the  child 
then  being  three  years  and  nine  months  old.  At  this  time  the  tumor 
was  well  flattened  out,  circular  in  outline,  extending  to  the  gluteal 
fold  on  the  left  side,  but  not  quite  as  far  as  this  on  the  right  side ; 
anteriorly  it  went  to  the  anal  margin  in  the  middle  line  and  in  front 
of  the  anus  on  the  right  side.  Above  it  was  limited  by  the  middle  of 
the  sacrum.  Its  diameter  was  five  inches  ;  in  size  it  was  somewhat 
larger  than  a  man's  fist,  well  flattened  out.  The  skin  over  it  seemed 
rather  thick  ;  it  was  movable  in  places.  Here  and  there  it  was  thrown 
into  deep  folds,  and  at  these  folds  the  skin  was  tightly  adherent.     At 


446  POWERS, 

the  right  extremity  a  hard  nodule,  an  inch  and  a  quarter  long  and 
one-half  inch  wide,  was  plainly  felt.  This  nodule  or  lump  could  be 
bent  slightly  on  itself.  It  moved  freely  on  the  deep  parts,  but  the 
skin  over  it  was  attached.  The  entire  mass  was  movable.  As  the 
child  lay  on  its  mother's  lap  and  kicked  its  legs,  the  upper  lateral  parts 
of  the  tumor  moved,  the  skin  over  it  being  thrown  into  deeper  folds. 
The  mass  was  nowhere  tender  or  inflamed.  It  seemed  to  be  solid 
throughout.     Rectal  examination  was  negative. 

This  boy  is  well  developed,  strong  and  healthy.  He  plays  about 
like  other  youngsters  of  his  age,  and  has  no  symptoms  whatever  refer- 
able to  the  lower  extremities.  He  runs  about,  lies  on  his  back,  and 
sits  like  other  children.  He  does  not  favor  this  portion  of  his  body 
in  any  way — in  a  word,  except  for  its  mere  presence,  this  tumor  gives 
no  general  or  local  symptoms.     The  boy  never  seems  conscious  of  it. 

Some  variety  of  congenital  malformation  of  the  sacrococcy- 
geal region  is  very  common.  That  most  often  seen  is  the  simple 
dimple  or  groove,  the  so-called  fovea  coccygea.  Beyond  this 
we  have  the  epidermoid  fistula  or  pilonidal  sinus,  and  a  step 
further  brings  the  true  dermoid.  In  this  class  also  may  be 
placed  sacculation  of  the  cord  connected  with  vertebral  fissures, 
spina  bifida  occulta. 

All  the  foregoing  are  of  single  germinal  formation.  The 
more  complex  growths  are  of  double  germinal  substratum  ; 
complete  or  incomplete  double  formations,  and  parasitic  cystic 
mixed  tumors  (teratomata-embryoid  tumors).  I  believe  that 
the  case  heretofore  related  belongs  to  the  last  class,  and,  while 
it  lacks  histological  confirmation,  one  may  reason  by  analogy 
from  similar  growths  which  have  been  pathologically  examined. 

These  sacrococcygeal  teratomata  present  the  greatest  diver- 
sities of  tissue.  They  form  a  class  of  tumors  by  themselves. 
They  are  generally  mixed,  and  in  addition  to  the  structure  of 
dermoids  they  may  and  often  do  present  cysts  lined  with  cili- 
ated, flat  or  columnar  epithelium,  muscle  fibre,  nerve  tissue, 
intestinal  remnants,  bone  and  cartilage.  Rindfleisch  names 
such  a  growth  a '*  histological  potpourri."  The  region  itself 
presents  as  much  diversity  of  structure  as  does  that  of  the 
face. 


GIANT    SACROCOCCYGEAL    TUMORS.  447 

Stolper'  has  recently  given  the  subject  careful  attention.  He 
approaches  it  almost  entirely  from  the  genetic  or  histological 
stand-point.  He  found  that  many  cases  of  spina  bifida  are  mul- 
tilocular,  and  can  be  told  from  teratoid  tumors  only  by  micro- 
scopical study;  combination  of  both  forms  may  occur.  Stolper 
afifirms  that  it  has  not  yet  been  proven  that  the  remnant  of  the 
medullary  canal,  a  persistent  coccygeal  vertebra,  the  neuro- 
enteric  duct,  or  Luschka's  gland,  may  be  the  starting-point  of 
such  a  growth,  though  the  possibility  of  this  is  not  denied.  One 
thing  is  certain,  and  that  is  that  teratoid  tumors  of  the  sacro- 
coccygeal region  unanimously  show  components  from  all  three 
of  the  germinal  layers.  Variations  in  the  mode  of  growth  are 
responsible  for  the  great  disparity  in  the  microscopical  appear- 
ances. The  manifold  coarse  and  fine  structure,  the  indica- 
tions of  so  many  different  organs,  the  cyst  formation,  the 
differences  in  the  epithelium  in  one  and  the  same  cyst  are 
readily  explained  by  the  assumption  of  a  double  germinal  sub- 
strata. 

Fig.  7  is  from  a  photograph  of  a  remarkable  case  which  was 
under  Stolper's  observation,  a  giant  sacrococcygeal  tumor  in  a 
child  five  months  of  age. 

Stolper's  observations  seem  to  be  confirmed  by  a  recent  case 
reported  by  Hagen-Torn.-  This  concerns  a  very  interesting 
case  of  congenital  sacral  tumor,  which,  in  addition  to  many 
forms  of  intestinal  tissue,  contained  sarcomatous  and  myxo-sar- 
comatous  degeneration.  He  considers  it  a  malignant  degener- 
ation of  a  sarcomatous  nature,  which  had  its  origin  in  a  small, 
double  germinal  malformation. 

Phocas,  of  Lille,-^  reports  two  cases.  One  a  five"year-old  child 
presenting  a  tumor  twelve  centimetres  in  breadth  by  eleven 
centimetres  in  thickness,  and  a  second  child  of  twenty-two 
months  with  a  tumor  forty-three  centimetres  in  circumference, 
the  pedicle  of  which  measured  nine  centimetres  in  breadth  and 
twenty-five  centimetres   in   circumference.     Both   tumors  were 

1  Deutsch  Zeitschrift  fiir  Chir.,  Band  1. 

2  V.  Langenbeck's  Archiv,  Band  Ix.,  Heft  3. 

■''  Bull,  et  mem.  de  la  soc.  de  chir.  de  Paris,  t.  xxii.  p.  847. 


448  POWERS, 

markedly  cystic,  and  both  showed  the  most  diverse  tissue  con- 
stituents.    Extirpation  was  successful  in  both  cases. 

Phocas  advises  delay  in  these  cases  until  the  children  reach 
such  age  as  to  enable  them  to  withstand  operation.  When  the 
tumors  are  very  large  it  may  be  better  to  extirpate  them  in 
multiple  sittings. 

Broca  and  Cazin^  made  careful  examination  of  two  specimens, 
one  from  a  child  of  six  weeks,  the  other  from  a  child  of  four 
years.  Both  operations  were  successful,  and  both  specimens 
showed  sections  of  intestine,  having  about  the  diameter  of  a 
goose-quill,  laid  down  in  the  midst  of  large  masses  of  small 
cysts.  The  microscopical  evidences  of  the  intestine  were  char- 
acteristic. The  cysts  were  lined  with  ciliated  epithelium.  The 
authors  believe  the  tumors  to  have  sprung  from  the  neuro- 
enteric  canal. 

Calbet"  discusses  six  teratogenetic  tumors  at  length,  and  ar- 
rives at  the  conclusion  that  twin  monstrosities  and  congenital 
sacrococcygeal  tumors  belong  practically  in  the  same  class,  and 
that  microscopical  investigation  will  show  all  possible  stages 
between  the  simplest  and  the  most  complicated  growths. 

Nasse^  reports  on  five  congenital  coccygeal  tumors,  each  of 
which  had  a  ventral  seat.  Some  of  these  operations  were 
exceedingly  difficult ;  the  cysts  reached  so  high  in  the  pelvis 
that  they  could  not  be  extirpated  m  toto.  The  most  diverse 
tissues  were  found  in  these  tumors:  connective  tissue,  bone, 
cartilage,  flat  muscle  fibre,  conglomerate  glands,  mucous  cysts, 
which  showed  in  part  ciliated  epithelium  and  in  places  a  trans- 
ition from  squamous  to  cylindrical  epithelium.  One  of  these 
tumors  was  a  simple  dermoid.  The  author  assumes  that  the 
other  four  arose  from  the  post-anal  remains  of  the  intestinal 
tract.  Nasse  says  that  while  teratomata  of  dorsal  growth  often 
contain  nerve  tissue,  those  ventrally  situated  are  generally 
cystic. 

Perman,  of  Stockholm,^  reports  an  operation  on  a  five-months- 

1   Revue  d'Orthopedie,  1895,  No.  6.  «  Th^se  de  Paris,  1893. 

3  Centralblalt  fiir  Chir.,  v.  19,  p.  1077. 

*  V.  Langenbeck's  Archiv,  Band  xlix.,  Heft  3. 


Flc.  I. 


Congenital  sacrococcygeal  tumor ;  child  three  months  old. 


Fig.  2. 


The  same. 


Fig.  3. 


The  same  at  three  and  a  half  years  of  age. 


Fig.  4. 


I  he  same. 


Fig.  s. 


The  same. 


Fig.  6. 


The  same.  Figs.  3,  4,  5  and  6  are  to  be  compared  with 
Figs.  I  and  2,  in  order  to  show  the  spontaneous  contrac- 
ture which  the  tumor  has  undergone. 


Fig.  7. 


Fig  8. 


Fig.  9. 


(JIANr    SACKOCOCCYGEAL    TUMORS.  449 

old  child  who  had  a  cystic  sacrococcygeal  teratoma  the  size  of 
a  baby's  head.  The  mass  was  limited  below  by  the  gluteal  fold, 
on  the  right  side  it  reached  to  the  trochanter  major,  and  it 
stretched  some  two  inches  across  the  middle  line  in  the  sacral 
region.  The  skin  over  it  was  very  thin  and  movable.  On 
operation  several  large  cysts  and  many  small  ones  were  found, 
together  with  masses  of  gliomatous  tissue.  Large  nerve  fibres 
could  not  be  demonstrated.  Here  and  there  cubical  and  cylin- 
drical epithelium.  The  coccyx  was  pressed  somewhat  to  the  left 
side,  but  no  gap  in  the  spinal  column  could  be  discovered.  The 
child  recovered.  From  the  presence  of  the  large  amount  of 
gliomatous  tissue  Perman  assumes  that  the  structure  came  from 
the  same  embryonal  tissue  as  the  brain  and  spinal  cord. 

Ritschl'  removed  a  tumor  the  size  of  a  child's  head  from  the 
sacral  region.  The  mass  was  found  to  be  made  up  of  many 
different  tissues,  in  part  cystic  and  in  part  solid.  "  Character- 
istic fetal  rudiments." 

Other  and  similar  observations  might  be  cited,  but  I  believe 
that  the  foregoing  tend  to  strengthen  the  assumption  that  the 
case  which  I  report  may  properly  be  placed  in  the  class  of  tera- 
tomata  and  embryoid  growths.  Its  appearance  at  birth  and  a 
few  months  thereafter,  its  partly  cystic  and  partly  solid  nature, 
its  size  and  seat,  all  place  it  in  line  with  the  cases  histologically 
examined  by  Stolper  and  others.  However  instructive  it  might 
be  to  add  the  pathological  report,  I  am  quite  content  to  have 
had  the  tumor  undergo  spontaneous  contraction.  The  age, 
size,  and  strength  of  the  child,  the  absence  of  local  pain,  ten- 
derness, and  ulceration,  the  progressive  shrinkage  of  the  tumor 
itself,  all  lead  me  to  hope  that  nature  may  have  cured  the  con- 
dition. It  is  possible  that  further  growth  may  take  place,  and 
that  malignant  degeneration  may  ensue  as  time  goes  by.  I  am 
unable  to  obtain  record  of  any  case  in  which  a  similar  tumor 
has  pursued  the  course  of  this  one. 

1   Beitrage  zur  klin.  Chir.,  Band  viii. 


Am  Surg 


CICATRICIAL    STRICTURE    OF    THE    CESOPHAGUS. 
GASTROSTOMY,  WITH  RETROGRADE  DILA- 
TATION   OF  THE    STRICTURE    BY 
RUBBER  TUBES. 


By  henry  R.  WHARTON,  M.D  , 

PHILADELPHIA. 


Robert  N.,  aged  seven  years,  was  admitted  to  the  medical  ward 
of  the  Children's  Hospital,  October  13,  1900,  with  the  following 
history :  Four  weeks  before  his  admission  he  had  swallowed  a  solution 
of  lye,  which  was  immediately  followed  by  difficulty  in  swallowing 
and  vomiting;  these  symptoms  persisted,  and  he  gradually  lost 
strength  and  weight,  and  at  the  time  of  his  admission  weighed  only 
twenty-seven  pounds. 

x\ttempts  to  pass  an  oesophageal  bougie  were  unsuccessful.  He  was 
also  made  to  swallow  several  small  silver  shot  attached  to  fine  silken 
threads,  in  hope  these  would  pass  the  obstruction. 

He  was  transferred  to  the  surgical  ward  on  December  8th,  and 
upon  examining  the  oesophagus  with  a  bougie  I  found  that  its  point 
was  arrested  at  a  point  nine  inches  below  the  incisor  teeth,  and  it 
was  found  impossible  to  pass  even  the  smallest  bougie.  He  was 
nourished  at  this  time  largely  by  nutritious  enemata. 

As  he  was  gradually  losing  weight,  gastrostomy  was  performed  on 
December  19th,  the  walls  of  the  stomach  simply  being  sutured  to  the 
edges  of  the  abdominal  wound  by  deep  sutures,  and  a  fair-sized 
opening  made  into  the  stomach.  I  then  endeavored  to  pass  a  small- 
sized  bjugie  through  the  stricture  from  the  cardiac  orifice  of  the 
stomach,  but  was  unsuccessful.  The  patient  was  nourished  for  some 
time  by  food  introduced  through  the  artificial  opening,  and  gained 
gradually  in  weight. 

Several  weeks  later  he  was  etherized,  and  a  No.  2  flexible  English 
catheter  was  passed  through   the  stricture  from  the  mouth,  and  its 


CICATRICIAL    STRICTURE    OF    THK    CESOPHAGUS.       45  I 

point,  guided  by  the  finger  in  tlie  stomach,  was  brought  out  of  the 
artificial  opening  in  the  stomach  ;  to  this  was  attached,  by  a  strong  silk 
ligature,  twelve  inches  in  length,  a  small  rubber  drainage-tube,  which 
was  drawn  through  the  stricture  by  withdrawing  the  catheter,  the 
tube  being  well  stretched  as  it  was  drawn  through  the  stricture ;  the 
tube  was  drawn  upward  until  its  upper  extremity  was  well  up  in  the 
oesophagus.  A  silk  ligature  was  next  tied  to  the  lower  extremity  of 
the  rubber  tube,  and  its  ead  was  allowed  to  drop  back  into  the  cavity 
of  the  stomach.  The  ligature  projecting  from  the  mouth  was  then 
secured  to  that  passing  out  of  the  opening  in  the  stomach.  The 
stricture  was  dilated  at  intervals  of  a  few  days  by  attaching  larger 
rubber  tubes  to  the  ligature  passing  from  the  opening  in  the  stomach, 
and  by  allowing  the  tubes,  which  were  drawn  through  the  stricture 
under  tension,  to  remain  for  a  few  days,  fair  dilatation  of  the  stricture 
was  accornplisiied.  After  removing  the  rubber  tube  it  was  found  pos- 
sible to  pass  bougies  from  the  mouth  through  the  stricture,  gradually 
increasing  their  size.  It  was  found,  however,'  that  as  the  patient 
began  to  take  nourishment  by  the  mouth,  a  considerable  amount 
of  it  escaped  from  the  fistula,  and  he  again  began  to  lose  weight, 
which  was  at  this  time  twenty-six  pounds. 

I  next  decided  to  close  the  gastric  fistula,  which  was  done  by 
making  an  elliptical  incision  around  the  gastric  fistula,  about  an 
eighth  of  an  inch  from  its  edges  ;  the  tissues  were  next  dissected 
loose  close  to  the  fistula  and  invaginated,  so  that  the  raw  surface  of 
the  flaps  came  in  contact;  these  were  secured  in  this  position  by  six 
silk  sutures.  The  inverted  flaps  were  then  covered  by  dissecting 
flaps  from  the  outer  edge  of  the  incision  and  sliding  them  over  the 
position  of  the  opening  and  securing  them  by  sutures.  The  patient 
did  well  after  this  operation,  and  the  fistula  closed. 

The  patient  is  now  taking  nourishment  well  by  the  mouth,  and  has 
gained  in  weight,  now  weighing  thirty-eight  pounds.  The  dilatation 
of  the  stricture  is  still  practised  at  intervals  of  a  few  days. 

Remarks.  The  great  majority  of  strictures  of  the  oesophagus 
occurring  in  children  result  from  the  swallowing  of  lye.  All 
strictures  of  the  cesophagus  which  have  come  under  my  obser- 
vation have  resulted  from  this  cause,  with  two  exceptions.  In 
one  case  the  stiicture  followed  an  attack  of  diphtheria,  and  in 
the  other  it  occurred  as  a  sequela  of  typhoid  fever.     Professor 


45  2  WHARTON, 

Alex.  Johannersen/  of  Christiana,  reports  140  cases  of  lye- 
poisoning  in  children,  and  V.  Torday,^  of  Budapest,  reports  70 
cases  of  the  same  affection  coming  under  his  personal  observa- 
tion. The  frequency  of  this  accident  in  the  countries  from 
which  these  cases  are  reported  is  accounted  for  by  the  fact  that 
lye,  either  in  the  solid  form  or  in  concentrated  solution,  is 
largely  used  for  domestic  purposes  in  the  place  of  soap. 

In  Johannersen's  140  cases  the  mortality  was  8.6  per  cent., 
the  causes  of  death  being  acute  poisoning  (intoxicatia  alkalina), 
six;  perforation  of  right  pleura  (from  sounding),  one;  hemor- 
rhage from  mouth  (cause  unknown),  one ;  bronchopneumonia, 
one  ;  empyema,  one ;  noma,  one ;  purulent  pericarditis,  pleu- 
ritis,  and  pneumonia,  one  each. 

In  74  cases  a  stricture  of  the  oesophagus  resulted.  In  104 
cases  in  which  bougies  were  passed,  53.8  per  cent,  were  cured 
by  dilatation,  being  dilated  sooner  or  later  to  30  Chariere  scale. 
In  46.2  per  cent,  some  narrowing  of  the  oesophagus  remained  in 
spite  of  sounds  passed  by  the  mouth,  3  cases  being  impassable  ; 
others  were  permeable  by  sounds  varying  from  No.  10  to  No.  29. 
Two  of  the  fully  dilated  cases  died.  Two  experienced  recon- 
traction.  Of  the  48  cases  not  fully  dilated  or  impassable,  i  died 
from  perforation  of  the  right  pleura,  3  had  gastrostomy  per- 
formed, with  2  recoveries  and  i  death ;  i  case  had  external 
cesophagotomy  performed,  with  a  favorable  result. 

The  same  authority  mentions  46  cases  collected  by  Keller, 
with  a  mortality  of  14.3  per  cent.,  76  per  cent,  of  these  cases 
having  had  well-marked  stricture  of  the  oesophagus  ;  of  these 
65.7  per  cent,  were  cured,  3  improved,  5  died,  and  in  the  remain- 
der the  ultimate  result  was  unknown.  In  Hacker's  collection 
of  333  cases,  52.2  per  cent,  had  strictures,  and  26.4  per  cent, 
died.  In  Van  Falck's  27  cases,  81.5  per  cent.  died.  In  Lewin's 
89  cases,  60  per  cent.  died.  Robert  estimates  the  mortality 
from  cicatricial  stricture  of  the  oesophagus  at  from  60  to  80 
per  cent. 

It  is  difficult  to  estimate  definitely  the  mortality,  as  the  ulti- 
mate result  in  many  cases  cannot  be  ascertained.    V.  Torday,  in 

•  Jahrbuch  f.  Kinderheilkunde,  February  6,  1901.  '^  Ibid.,  3d  series,  Band  liii. 


CICATRICIAL    STRICTURE    OF    THE    QiSOPHAGUS.       453 

70  cases  of  cicatricial  stricture  of  the  (L-sophagus  resulting  from 
the  swallowing  of  lye,  excluding  those  who  died  of  perforation, 
states  that  6  died  of  intercurrent  disease,  3  were  removed  by 
parents  without  treatment,  30  were  dilated  to  15  English  scale, 
12  to  12,  5  to  II. 

Stricture  of  the  oesophagus  following  lye  results,  sooner  or 
later,  in  a  large  majority  of  the  cases,  occurring  in  74  per  cent, 
in  Johannersen's  cases,  and  j^  per  cent,  of  Keller's,  and  in  52.2 
per  cent,  of  Hacker's  cases.  The  methods  of  treatment  which 
are  employed  for  the  cure  of  cicatricial  stricture  of  the 
oesophagus,  are  (i)  gradual  dilatation  by  bougies;  (2)  tubage ; 
(3)  oesophagotomy,  internal  or  external ;  (4)  gastrostomy,  fol- 
lowed by  the  "  string  "  method,  and  dilatation  with  elastic  tubes, 
and  sometimes  combined  with  cesophagotomy. 

1.  Gradual  dilatation  by  bo2tgics  is  the  safest  method,  and  if 
employed  early  is  very  successful.  This  operation  is  not 
entirely  free  from  danger,  as  one  of  Johannersen's  cases  died 
from  perforation  of  the  pleura  in  passing  a  sound,  and  in  120 
cases  reported  by  Torday,  in  which  dilatation  was  practised, 
eight  perforations  occurred,  giving  a  mortality  of  6.6  per  cent,  by 
this  method.  This  accident  seems  to  be  more  common  in  cases 
of  stricture  of  some  standing  in  which  diverticuli  have  formed 
above  the  strictures.  Torday  considers  that  the  prognosis  in 
cicatricial  strictures  of  the  oesophagus  in  children  is  favorable, 
as  the  gradual  growth  of  the  oesophagus  favors  the  artificial 
dilatation  of  the  stricture  if  the  stricture  is  not  annular. 

In  104  of  Johannersen's  cases  in  which  dilatation  by  bougies 
was  practised,  53.8  per  cent,  were  cured,  while  in  46.2  per  cent, 
some  narrowing  remained.  In  view  of  the  mortality  which  has 
occurred  from  perforation  with  the  bougie  during  dilatation,  it 
is  important  that  the  greatest  care  and  gentleness  should  be 
exercised  in  its  passage. 

2.  Tubage.  This  consists  in  the  passage  of  specially  con- 
structed hard-rubber  tubes  of  different  sizes  and  lengths  through 
the  stricture.  These  are  introduced  by  an  instrument  through 
the  stricture,  and  are  allowed  to  remain  in  place  as  an  intuba- 
tion-tube is  allowed  to  remain  in  the  larynx.     They  have  been 


454  WHARTON, 

employed  to  some  extent  in  the  malignant  strictures  of  the 
oesophagus,  btat  I  am  not  aware  that  they  have  been  used  in 
cicatricial  strictures  following  the  swallowing  of  lye,  although, 
in  properly  selected  cases,  they  might  be  employed  with 
advantage. 

3.  CEsvphagoiomy,  internal  or  external^  has  been  employed  in 
a  number  of  cases  with  success,  but  this  operation  is  only 
applicable  to  strictures  involving  the  upper  portion  of  the 
oesophagus.  This  operation  is  sometimes  combined  with 
gastrostomy. 

Johannersen  records  i  case  of  external  cesophagotomy  with 
a  favorable  result.  Torday  records  15  oesophagotomies  for 
cicatricial  stricture  of  the  oesophagus,  with  the  following  results  : 
In  8  cases  in  which  external  cesophagotomy  alone  was  prac- 
tised, four  died  and  four  recovered.  In  2  cases  of  external  and 
internal  cesophagotomy,  two  recoveries  occurred.  In  5  cases  in 
which  cesophagotomy  and  gastrostomy  were  combined,  five 
recoveries  took  place.  In  3  cases  in  which  internal  cesopha- 
gotomy alone  was  practised,  two  died  and  one  recovered. 

4.  Gastrostomy.  The  operation  of  gastrostomy  may  be 
required  as  a  means  of  nourishing  the  patient  and  also  to  gain 
access  to  the  stricture  for  its  treatment.  The  modern  operations 
of  gastrostomy,  such  as  Witzel's,  or  Ssabanejew-Frank's,  which 
aim  to  prevent  leakage  from  the  fistula  in  the  stomach,  cannot 
be  employed  with  advantage  in  the  treatment  of  stricture  of  the 
oesophagus,  as  they  do  not  permit  of  the  introduction  of  the 
finger  or  instruments  into  the  stomach  for  this  purpose.  We 
therefore  generally  have  to  resort  to  the  old  method  of  gas- 
trostomy, which  simply  secures  the  walls  of  the  stomach  to  the 
edges  of  the  abdominal  wound,  or  the  method  of  gastrostomy 
which  was  described  by  Stamm,  and  which  was  employed  suc- 
cessfully by  Curtis  in  a  case  of  stricture  of  the  oesophagus.  This 
method  possesses  the  advantage  of  preventing  leakage,  even 
when  a  string  is  present  in  the  fistula.  Stamm's'  method  con- 
sists in  inserting  the  catheter  through  a  small    opening  made 

•   Medical  News,  September  22,  1894. 


CICATRICIAL    STKlCrURE    OK    THE    CESOPHAGUS.       455 

in  the  stomach,  and  then  inverting  the  wall  of  the  latter  in 
a  funnel-shaped  manner  by  two  purse-string  sutures  surround- 
ing the  opening.  The  first  suture  is  passed  about  half  an 
inch  from  the  edge  of  the  opening,  the  needle  picking  up  only 
the  outer  coats  of  the  stomach,  making  a  complete  circle 
around  the  opening.  The  stomach-wall  within  this  circle  is 
inverted  and  the  suture  tied  so  as  to  pucker  up  the  tissues 
around  the  catheter.  A  similar  suture  is  then  passed  half  an 
inch  from  the  first,  and  secured  in  the  same  way,  and  next  both 
ends  of  the  purse-string  suture  are  armed  with  needles  and 
passed  through  the  entire  thickness  of  the  abdominal  walls  on 
both  sides  of  the  wound  and  tied  in  a  loop.  Thus  there  results 
a  nipple-like  protrusion  of  the  wall  of  the  stomach  inside  the 
organ  around  the  catheter,  which  acts  as  a  valve  and  prevents 
the  escape  of  the  contents  of  the  stomach  when  the  tube  is 
withdrawn.  The  fistula  thus  formed  usually  closes  spontane- 
ously when  no  longer  required. 

The  disadvantage  of  a  gastric  fistula  made  by  the  old  method, 
if  it  is  large  enough  to  permit  of  the  manipulation  with  instru- 
ments or  the  finger,  is  it  is  apt  to  be  followed  by  leakage,  which 
may  be  so  free  that  the  patient  does  not  retain  sufficient  nour- 
ishment. When  a  gastric  fistula  has  been  established  attempts 
should  be  made  to  pass  a  small  bougie  from  the  mouth  through 
the  stricture  into  the  stomach,  or  to  pass  it  from  the  cardiac 
orifice  of  the  stomach  through  the  stricture,  and  bring  it  out  of 
the  mouth.  Retrograde  dilatation  by  bougies  or  rubber  tubing, 
as  was  practised  in  this  case,  can  often  be  accomplished  when 
it  is  found  impossible  to  pass  an  instrument  by  the  mouth,  this 
probably  being  due  to  the  fact  that  a  diverticulum  exists  which 
prevents  the  passage  of  an  instrument  by  the  mouth.  When 
this  bougie  has  been  passed  a  strong  silk  ligature  is  attached 
to  its  end,  and  it  is  drawn  through  the  stricture ;  the  method 
of  Abbey  can  then  be  practised,  which  consists  in  sawing  the 
stricture  by  means  of  the  string,  one  end  of  which  is  held  in  the 
mouth,  and  the  other  end  of  which  is  held  by  the  finger  inserted 
into  the  stomach  ;  after  the  stricture  has  been  slightly  enlarged 
in   this   manner  it  is    subsequently  treated  by  dilatation  with 


456      CICATRICIAL    STRICTURE    OF    THE    CESOPHAGUS. 

bougies.  Another  method  consists  in  attaching  a  small  rubber 
tube  to  either  the  end  of  the  string  protruding  from  the 
stomach  or  that  protruding  from  the  mouth,  and  drawing  it 
through  the  stricture  under  tension,  and  allowing  it  to  remain 
in  position  for  twenty-four  hours,  so  that  by  exerting  elastic 
pressure  upon  the  walls  of  the  stricture  dilatation  may  be 
accomplished.  When  the  rubber  tubing  has  once  been  passed, 
the  string,  by  means  of  which  it  has  been  drawn  through  the 
stricture,  should  be  secured  to  the  other  end  of  the  tubing.  If 
the  tube  is  drawn  from  the  stomach  upward  the  upper  extremity 
of  the  tube  should  not  pass  beyond  the  lower  portion  of  the 
larynx,  so  that  the  silk  thread  only  protrudes  from  the  mouth, 
which  is  less  likely  to  produce  gagging  than  if  the  tube  occu- 
pies this  position.  Rubber  tubing,  gradually  increased  in  size, 
is  passed  at  intervals  of  a  few  days  until  the  stricture  is  suffi- 
ciently dilated  to  allow  the  passage  of  a  fair-sized  bougie. 
After  this  has  been  accomplished,  the  dilatation  can  be  kept  up 
by  the  passage  of  bougies,  and  the  patient  can  take  a  sufficient 
quantity  of  nourishment.  The  gastric  fistula  may  be  allowed 
to  close  spontaneously,  or  be  closed  by  a  plastic  operation. 

Johannersen  records  three  gastrostomies  in  his  collection  of 
cases,  with  two  recoveries  and  one  death.  Torday  has  collected 
26  cases  of  cicatricial  stricture  of  the  cesophagus  in  which  gas- 
trostomy was  performed.  In  19  cases  of  simple  gastrostomy 
there  were  twelve  recoveries  and  seven  deaths,  the  latter  being 
due  to  peritonitis  and  other  complications.  Two  cases  recov- 
ered, but  had  a  permanent  gastric  fistula. 

In  5  cases  of  gastrostomy  combined  with  cesophagotomy 
there  were  5  recoveries. 


MOVABLE  KIDNEY  :  ITS  CAUSE  AND  TREATMENT. 


By  M.  L.  HARRIS,  M.D., 
CHICAGO.     • 


The  kidneys  are  usually  classed  as  fixed  organs.  They, 
however,  are  not  fixed,  but  possess  normally  quite  a  range  of 
motion.  This  varies  from  two  to  four  centimetres  in  a  longi- 
tudinal direction,  and  corresponds  to  the  rise  and  fall  of  the 
diaphragm  during  respiration.  As  a  rule,  the  normal  kidney 
cannot  be  palpated  through  the  intact  body  walls  in  men, 
but  in  women  the  right  can  be  distinctly  felt  in  a  majority 
of  the  cases,  and  the  left  in  a  smaller  proportion.  A  kidney 
may  often  be  easily  palpated  by  one  with  much  practice,  when 
another  with  less  experience  would  fail  to  perceive  it. 

In  palpating  a  kidney  the  patient,  with  all  clothing  about  the 
body  removed,  should  lie  on  the  side  opposite  the  organ  sought, 
with  the  head  and  shoulders  slightly  higher  than  the  hips,  and 
the  thighs  gently  flexed.  Standing-at  the  back  of  the  patient, 
the  fingers  of  one  hand  are  firmly  pressed  against  the  abdotni- 
nal  wall  just  below  the  costal  arch  and  to  the  outer  side  of  the 
rectus  muscle,  while,  with  the  fingers  of  the  opposite  hand,  firm 
counter-pressure  is  made  against  the  small  triangular  space  just 
below  the  twelfth  rib  behind.  The  patient  should  take  a  deep 
breath,  during  the  somewhat  rapid  exhalation  of  which  the 
kidney,  if  palpable,  may  be  grasped  between  the  two  hands. 
This  lateral  position  has  been  found  preferable,  as  a  rule,  to  the 
standing  position,  for  the  reason  that  many  patients,  even  with 
the  body  bent  forward  and  the  weight  resting  on  a  table,  are 
unable  to  relax  the  abdominal  muscles  as  completely  as  when 
lying  on  the  side.     It  is  often  possible  to  palpate  a  kidney  in 


458  HARRIS, 

the   lateral   position  which    could    not  be   felt  with  the  patient 
lying  on  the  back. 

For  the  sake  of  clearness,  it  is  necessary  to  define  what  is 
meant  by  a  palpable  and  movable  kidney.  In  almost  every 
individual  not  possessed  of  more  than  the  average  amount  of 
subcutaneous  fat  the  kidney  may  be  felt  in  the  sense  that,  with 
the  one  hand  firmly  pressed  in  the  triangular  space  below  the 
twelfth  rib  behind,  while  deep  pressure  with  the  other  hand  is 
made  in  front,  and  the  patient  take  a  deep  breath,  an  indistinct 
mass  will  be  felt  to  impinge  against  and  recede  from  the  hand 
placed  posteriorly.  Such  a  kidney,  however,  is  not  said  to  be 
palpable.  Only  when  a  portion  of  the  kidney  can  be  distinctly 
grasped  and  outlined  between  the  two  hands  is  it  said  to  be  pal- 
pable. One-third,  one-half,  or  two-thirds  of  the  kidney  may 
thus  be  palpated.  In  case  more  than  one-half  of  the  organ  can 
be  outlined,  and  it  can  be  caused  to  recede  out  of  reach  during 
exhalation,  it  is  said  to  be  movable  to  the  first  degree.  In  case 
both  hands  can  be  brought  together  above  the  organ,  it  is 
movable  to  the  second  degree,  and  if  it  can  be  depressed  to 
the  pelvic  brim  or  moved  to  beyond  the  mid-line,  it  is  movable 
to  the  third  degree. 

This  classification  is,  of  course,  arbitrary,  but  of  value  in 
facilitating  clearness  of  description.  The  great  frequency  of 
movable  kidney  in  women  has  only  recently  been  realized 
owing  to  a  more  systematic  examination  of  patients  with  this 
point  in  view.  Kiister^  found  that  the  4.41  per  cent,  of  the 
women  in  his  general  surgical  practice  had  movable  kidneys, 
while  Edebohls,  in  an  exclusively  gynecological  practice,  esti- 
mates that  20  per  cent,  are  thus  afflicted.  As  will  be  seen 
from  the  subjoined  table,  both  of  these  figures  are  very 
much  too  low,  as  my  figures  show  that  56  per  cent,  of  the 
women  had  distinctly  movable  kidneys  on  one  or  both  sides. 
What  are  the  causes  of  this  large  percentage  of  movable 
kidneys  in  women  ?  The  etiological  factors  usually  mentioned 
are  the  following  : 

'   Deutsch  Chir.  Lief,  52  B. 


MOVABLE     KIDNEY.  459 

Repeated  pregnancies,  which  are  supposed  to  act  by  pro- 
ducing a  relaxation  of  the  anterior  abdominal  walls,  thus  dimin- 
ishing the  abdominal  pressure  against  the  kidneys,  as  well  as 
by  the  large  uterus  directly  displacing  these  organs ; 

Prolapse  of  the  uterus  and  vagina,  with  lacerations  of  the 
perineum  by  contributing  to  the  reduction  of  intra-abdominal 
tension  ; 

Retrodisplacement  of  the  uterus  by  drawing  on  the  ureters  ; 

The  rapid  absorption  of  the  perirenal  fat,  as  may  occur  in 
acute  wasting  diseases  ; 

Drawing  on  the  kidneys  by  the  transverse  mesocolon  in 
enteroptosis  or  Glcnard's  disease; 

The  relaxation  of  the  abdominal  walls  which  follows  the 
removal  of  large  intra-abdominal  tumors  or  ascitic  accumu- 
lations. 

That  these  factors  have  very  little  or  no  influence  in  giving 
rise  to  movable  kidneys  will  be  clearly  shown. 

The  fallacy  of  supposing  that  pregnancy,  lacerations  of  the 
perineum,  displacements  of  the  uterus,  etc.,  are  instrumental  in 
causing  movable  kidneys  is  unanswerably  shown  by  the  fact 
that  over  40  per  cent,  of  the  cases  of  movable  kidneys  were 
found  in  unmarried  women ;  in  women  who  have  thus  never 
been  pregnant,  who  have  intact  perineal  floors,  and  whose  uteri 
are  in  normal  position.  That  these  factors  may,  and  perhaps 
at  times  do,  aggravate  the  condition  caused  by  other  influences 
is  admitted. 

The  fallacy  of  the  theory  of  the  absorption  of  the  perirenal 
fat  has  been  shown  by  Heller,  and  of  the  traction  theory  by 
Ewald.  The  influence  of  traumata,  both  internal  and  external, 
will  be  considered  later.  What,  then,  is  the  fundamental  cause 
of  movable  kidney?  This  is  found  in  the  relation  which  exists 
between  the  location  of  the  kidney  and  the  body  form. 

The  exhaustive  work  of  VVolkow  and  Delitzin  renders  it 
unnecessary  to  enter  into  a  study  of  the  location  of  the  kidney 
as  found  in  the  dead-house.  Conclusions,  however,  based 
entirely  on  dead-house  findings  are  erroneous,  for  the  reasons 
that  when  the  body  is   in   the  recumbent  position  the  kidney 


460  HARRIS, 

assumes  its  highest  or  most  cephalad  location;  that  this  loca- 
tion is  moved  still  further  cephalad  by  the  final  contraction 
of  the  chest  at  death,  and  last,  because  the  kidney  loses  much 
of  its  mobility  owing  to  the  post-mortem  solidification  of  the 
perirenal  fat. 

These  studies  are,  therefore,  based  upon  observations  made  on 
the  living  subject  in  the  examining-room  and  on  the  operating- 
table.  While  systematically  examining  patients  in  Litten's  clinic, 
Becker  and  Lennhoff^  became  convinced  that  they  were  able  to 
predict  from  the  general  appearance  of  the  body-form  of  a 
woman  whether  the  kidneys  would  be  found  palpable  or  not. 
In  order  to  reduce  this  conviction  to  some  tangible  shape  a 
series  of  measurements  of  the  women  examined  was  made, 
which  eventuated  in  what  they  termed  the  index  of  the  body- 
form.  This  index  was  obtained  by  dividing  the  distance  from 
the  suprasternal  notch  to  the  upper  edge  of  the  symphysis 
pubis  by  the  least  circumference  of  the  abdomen  and  multiply- 
ing by  100.  They  found  that  in  women  with  a  high  index  the 
kidney  was  usually  palpable,  while  in  those  with  a  low  index 
it  was  not  palpable.     The  average  index  was  seventy-seven. 

They  therefore  divided  the  patients  into  positive,  or  those 
with  an  index  above  seventy-seven,  in  whom  the  kidney  could 
be  felt;  and  negative,  or  those  whose  index  was  below  seventy- 
five,  and  whose  kidneys  could  not  be  felt.  Before  the  appear- 
ance of  Becker  and  Lennhoff's  article  I  had  made  some  obser- 
vations on  the  body-form  in  its  relation  to  the  kidney,  which 
were  inspired  by  Kiister's  article  in  1895,  on  the  cause  of  sub- 
cutaneous lacerations  of  the  kidney  and  of  movable  kidney.' 
Kiister's  observations  I  was  able  to  confirm  many  times  during 
my  course  on  operative  surgery  on  the  cadaver  as  well  as  by 
observations  on  the  living  subject.  I  then  began  a  more  sys- 
tematic study  of  movable  kidneys  and  the  location  of  the 
kidney  in  its  relations  to  the  body-form,  or  rather  the  influence 
of  the  body-form  on  the  location  of  the  kidney. 

'  Deutsch  med.  Woch.,  1898,  xxiv.,  S.  508. 
'•^  Arch.  f.  kliii.  Chir.,  1895,  No.  50,  S.  676. 


MOVABLE     KIDNEY.  461 

In  this  study  certain  measurements  of  the  body  were  taken, 
together  with  certain  other  data,  which  were  supposed  might  have 
a  bearing  on  the  subject.  It  was  soon  found  that  the  measure- 
ments taken  by  Becker  and  Lennhofif,  namely,  the  jugulo- 
symphisis  and  the  least  abdominal  circumference,  were  not 
sufficient  to  give  one  a  correct  idea  of  the  body-form,  nor  did 
these  measurements  offer,  in  any  way,  an  explanation  of  the 
fact  that  in  certain  cases  the  kidney  would  be  found  palpable, 
while  in  other  cases  it  could  not  be  felt.  Numerous  exceptions 
to  their  rule,  as  shown  by  themselves,  also  indicated  that  there 
were  other  factors  which  should  be  taken  into  consideration. 
In  order  to  determine  what  those  other  factors  were,  additional 
measurements  of  the  body  were  taken,  together  with  the  fol- 
lowing data:  Sex,  age,  married  or  single,  number  of  children, 
weight,  height,  condition  of  the  tenth  rib,  accidents,  such  as 
severe  falls  or  injuries  to  the  body,  and  the  condition  of  the 
pelvic  organs  and  perineum. 

For  purposes  of  this  study  the  body  cavity  may  be  sub- 
divided into  three  portions  or  zones,  the  upper  of  which  con- 
tains chiefly  the  lungs  and  heart;  the  middle  zone,  the  liver, 
stomach,  spleen,  pancreas,  and  major  portion  of  each  kidney; 
while  the  lower  zone  contains  the  intestinal  canal  and  a  minor 
portion  of  each  kidney.  The  true  pelvis  may  be  disregarded. 
A  transverse  plane,  passing  through  the  body  at  the  lower  end 
of  the  sternum  proper,  not  the  xiphoid  appendix,  forms  the 
lower  boundary  of  the  upper  zone,  and  a  similar  plane,  which 
cuts  the  lowermost  point  of  the  tenth  rib,  forms  the  lower 
boundary  of  the  middle  zone.  While  the  plane  forming  the 
boundary  between  the  upper  and  middle  zones  does  not,  of 
course,  accurately  separate  the  chest  from  the  abdomen,  it  may 
be  taken  as  such  for  practical  purposes,  and  has  been  found  to 
be  of  great  importance  in  determining  the  body-form  and  in 
estimating  the  capacity  of  the  middle  zone,  as  will  be  shown  in 
the  table  of  measurements. 

After  measuring  the  least  abdominal  circumferenoe  in  a  num- 
ber of  individuals  it  was  found  that  this  plane  was  not  fixed  in 
regard  to  its  location  ;  thus,  in  women,  while  it  usually  cut  the 


462  HARRIS, 

tenth  rib.  it  often  passes  below  this  point,  and  occasionally  was  as 
high  as  the  ninth  rib.  In  children  it  usually  passes  entirely  below 
the  ribs,  often  as  much  as  one  centimetre,  and  in  men  it  usually 
passes  just  below  the  tips  of  the  eleventh  and  twelfth  ribs.  It, 
therefore,  soon  became  evident  that  this  measurement  should  be 
taken  at  some  fixed  point  in  order  to  obtain  reliable  comparative 
results.  As  the  middle  zone  includes  that  portion  of  the  body 
cavity  which  is  partially  inclosed  by  the  lower  ribs,  its  lower 
boundary  should  correspond  with  the  lowest  point  of  these  ribs. 
The  tenth  rib  is  the  one  which  forms  the  lowest  point  laterally, 
and  in  measuring  the  circumference  of  the  body  at  this  point,  the 
tape  should  always  rest  on  the  lower  edge  of  the  tenth  rib  at  its 
lowest  part  instead  of  measuring  the  least  abdominal  circumfer- 
ence without  regard  to  its  location. 

In  taking  these  measurements  the  patient  should  lie  flat  on 
the  back.  If  the  shoulders  are  raised  any,  it  is  very  easy  to 
shorten  the  jugulo-symphysis  distance  one  to  three  centimetres, 
owing  to  the  forward  curve  of  the  body.  The  circumference  of 
the  body  at  the  tenth  rib  is  first  taken,  and  the  point  where  this 
line  crosses  the  middle  is  marked  with  a  pencil.  The  lower  end 
of  the  sternum  or  apex  of  the  costal  arch  is  marked,  and  the 
circumference  of  the  body  at  this  point  measured.  The  breasts 
should  be  drawn  upward  so  as  not  to  include  the  lower  part  of 
them  in  the  measurement.  Both  of  these  measurements  should 
be  taken  at  the  end  of  expiration  during  ordinary  respiration. 
The  jugulo-symphysis  is  the  distance  from  the  upper  end  of  the 
sternum  or  suprasternal  notch  to  the  upper  border  of  the  sym- 
physis pubis.  In  taking  this  measurement,  the  length  of  each 
zone,  upper,  middle,  and  lower,  should  also  be  separately  re- 
corded. By  dividing  the  jugulo-symphysis  b}^  the  circumference 
at  the  tenth  rib  an  "index"  was  obtained,  which,  in  the  table,  is 
marked  "Index  No.  i." 

In  measuring  the  circumference  in  the  manner  just  mentioned 
several  sources  of  error  were  observed  which  vitiated  somewhat 
the  results,  and  occasionally  made  them  appear  contradictory. 
Thus  it  was  found  in  measuring  the  abdominal  circumference 
that  the  deposit  of  fat  which  rounds  out  the  female  form  above 


MOVABLK     KIDNEY.  463 

the  hips  was  occasionally  so  great  that  the  circumference  was 
increased  out  of  proportion  to  the  inner  capacity.  The  same 
effect  was  produced  by  the  muscles  of  the  loin  in  some  women 
in  whom  a  marked  constriction  of  the  lower  ribs  is  present. 
The  measure  is  increased  if  taken  when  the  stomach  is  full  or 
distended. 

In  women  with  a  lax  or  pendulous  abdomen  with  visceral 
ptosis,  the  lower  ribs  spread  considerably  when  the  patient  is 
lying  down,  and  the  circumference  is  thus  increased  from  two  to 
five  centimetres  over  the  same  when  standing.  In  a  well-built 
person  with  firm  muscles  the  circumference  when  lying  differs 
little  or  not  at  all  from  the  same  when  standing.  In  case  the 
breasts  are  quite  large,  even  when  drawn  up  as  much  as  possible, 
the  circumference  of  the  body  at  the  lower  end  of  the  sternum 
is  increased  out  of  proportion  to  the  inner  capacity. 

As  the  object  of  the  measurements  is  to-  form  therefrom  an 
idea  of  the  relative  capacity  of  the  middle  zone  of  the  body,  it 
may  be  readily  seen  that  in  the  cases  just  mentioned  an  errone- 
ous conclusion  maybe  drawn.  Some  method  of  measuring  was 
therefore  sought  which  would  eliminate  these  errors.  This  was 
found  in  the  use  of  a  graduated  calipers. 

By  means  of  the  calipers  certain  diameters  of  the  body  could 
be  measured  opposite  fixed  points,  which  are  less  influenced  by 
varying  amounts  of  adipose  tissue  and  other  conditions  of  the 
body.  The  measurements,  taken  with  the  calipers,  are  five  in 
number,  namely : 

No.  I.  Lateral  diameter  of  the  body  on  a  plane  correspond- 
ing with  the  lower  end  of  the  sternum.  This  plane  at  its  widest 
lateral  diameter  usually  cuts  the  seventh  rib,  and  the  ends  of  the 
calipers  are  therefore  pressed  against  these  ribs  and  the  widest 
diameter  recorded.  This  measurement  is  called  the  upper  lateral 
diameter. 

No.  2.  Is  the  middle  lateral  diameter  and  is  the  greatest  dis- 
tance between  the  lower  edge  of  the  tenth  ribs.  Care  should 
be  taken  to  place  the  ends  of  the  calipers  against  the  lower  por- 
tion of  the  tenth  ribs  and  avoid  the  muscular  folds  often  present 
in  this  region. 


464  HARRIS, 

No.  3.  The  lower  lateral  diameter  is  the  widest  distance 
between  the  crests  of  the  ilia. 

No.  4.  The  upper  antero-posterior  diameter  extends  from  the 
lower  end  of  the  sternum  to  the  spinous  process  directly  oppo- 
site and  in  the  same  plane  as  the  upper  lateral  diameter. 

No.  5.  The  middle  antero-posterior  diameter  extends  from 
the  mid-line  in  front  to  the  spinous  process  opposite,  and  in 
the  same  plane  as  the  middle  lateral  diameter. 

These  measurements  should  be  taken  with  the  patient  stand- 
ing. 

The  cases  in  which  these  last  measurements  were  taken  in 
women  are  placed  by  themselves  and  labelled  "  Second  series." 
These  five  measurements  present  a  formula  which  may  be  said 
to  represent  each  a  particular  body-form.  By  dividing  the 
middle  lateral  diameter  by  the  upper  lateral  and  multiplying  by 
100  is  obtained  what  is  called  "  Index  No.  2."  By  a  careful 
consideration  of  these  tables  it  is  found  that  many  important 
and  interesting  conclusions  may  be  deduced  therefrom. 

As  women  are  the  most  frequent  sufferers  from  movable  kid- 
ney they  will  be  considered  first.  The  cases  are  arranged  in 
order,  based  on"  Index  No.  i,"  beginning  with  the  lowest  index 
and  ascending  to  the  highest.  In  the  "  Second  series"  the  same 
order  is  maintained,  and  next  to  "  Index  No.  i"  is  placed  "  Index 
No.  2  "  The  indices  are  simply  attempts  to  reduce  to  single 
figures  the  relations  between  certain  of  the  body  measurements, 
and  thus  represent  at  a  glance  the  body-form. 

"Index  No.  i"  shows  the  relation  which  exists  between  the 
length  of  the  body  cavity  and  its  circumference  at  the  lower 
edge  of  the  tenth  rib.  "  Index  No.  2"  refers  entirely  to  the 
middle  zone  of  the  body,  and  shows  the  relation  which  exists 
between  the  lateral  diameter  of  the  lower  end  of  this  zone  and 
that  of  the  upper  end,  or,  in  other  words,  the  amount  of  con- 
striction or  diminution  of  the  capacity  of  the  lower  end  as 
compared  with  the  upper. 

It  will  be  observed  that  the  column  marked  "  Index  No.  1" 
is  arranged  in  ascending  order,  and  that  the  location  or  condition 
of  the  kidneys,  as  noted  in  the  proper  columns,  is  found  to  be 


MOVABLE     KIDNEY.  465 

"  negative"  or  not  palpable  until  the  index  reaches  "j"]  to  78.  In 
those  cases  in  which  the  index  is  above  this  point,  either  one  or 
both  kidneys  are  found  to  be  palpable  or  movable  to  a  greater 
or  less  degree.  The  exceptions  to  this  rule  will  be  noted  later. 
If  all  cases  be  divided  into  "  negative"  and  "  positive"  there  will 
be  found  among  the  women  fifty-five  negative  and  seventy-one 
positive. 

That  all  cases  with  a  low  index  are  uniformly  negative  and 
those  with  a  high  index  uniformly  positive  cannot  be  due  to 
chance.  An  explanation  of  this  fact  will  be  found  in  a  study 
of  the  other  measurements  given  in  the  table.  Weight  is  found 
to  favor  the  negative  cases,  their  average  weight  being  58.7  kg., 
while  that  of  the  positive  is  54.5  kg.  In  height  the  positive 
exceed  the  negative  by  2.4  cm.,  their  average  heights  being 
respectively  160.4  cm.  and  162.8  cm.  Of  this  increase  in  height 
one-half  or  1.2  cm.  lies  in  the  length  of  the  body  or  jugulo- 
symphysis  and  the  remainder  in  the  extremities.  Average 
jugulo-symphysis  is  50.82  negative  and  52.03  positive. 

The  interesting  point  in  this  connection  is  the  distribution  of 
this  1.2  cm.  in  the  different  zones  of  the  body.  The  average 
length  of  the  different  zones  are  :  upper  zone,  14.55  cm.  for  the 
negative  and  14.58  cm.  for  the  positive;  middle  zone,  14  cm. 
for  the  negative  and  15. i  cm.  for  the  positive;  lower  zone,  22.27 
cm.  for  the  negative  and  22.33  cm.  for  the  positive.  It  will  thus 
be  seen  that  the  lengths  of  the  upper  and  lower  zones  remain 
about  the  same  in  the  two  classes  of  cases,  while  practically 
the  entire  increase  in  the  length  of  the  jugulo-symphysis  in  the 
positive  cases  over  the  negative  is  found  to  lie  in  the  middle 
zone. 

If  we  now  consider  the  average  circumference  of  the  middle 
zone  at  its  upper  and  lower  portion,  we  find  this  to  measure  77.1 
cm.  for  the  upper  and  69.5  cm.  for  the  lower  in  the  negative 
cases,  and  73.46  cm.  for  the  upper  and  61.9  cm.  for  the  lower 
in  the  positive  cases.  This  is  a  difference  of  7.6  cm.,  or  9.8  per 
cent.,  in  the  negatives,  and  11.56  cm.,  or  15.7  per  cent.,  in  the 
positives.  This  shows  that  there  is  a  marked  increased  contrac- 
tion or  diminution  in  size  of  the  lower  portion  of  the  middle 

Am  Surg  30 


466  HARRIS, 

zone  in  the  positive  cases  over  that  in  the  negative.  This  will 
be  still  better  shown  when  we  consider  the  diameters  taken  with 
the  calipers. 

If  the  middle  zone  were  a  true  conic  section,  with  a  greater 
and  smaller  circumference,  as  above  given,  the  middle  zone  in 
the  positive  cases  would  contain  nearly  800  c.c,  or  132  per 
cent,  less  than  the  same  in  the  negative  cases.  This  would  be 
equivalent  to  the  space  occupied  by  both  kidneys  and  the  spleen. 
Of  course,  in  this  estimate  no  allowance  has  been  made  for  the 
thickness  of  the  body-wall,  nor  for  the  marked  difference  between 
the  configuration  of  this  section  of  the  body  cavity  and  the 
external  surface.  It  simply  demonstrates  that  there  is  a  marked 
contraction  of  this  space  in  the  positive  cases  as  compared  with 
the  negative.  As  already  pointed  out,  certain  slight  errors  may 
occur  in  measuring  circumferences  which  are  practically  elimi- 
nated by  measuring  the  diameters  with  graduated  calipers. 

If  we  consider  now  these  diameters  we  find  that  in  the  nega- 
tive cases  the  average  upper  lateral  diameter  is  23.62  cm.;  aver- 
age middle  lateral  diameter,  20.2  cm. ;  average  lower  lateral 
diameter,  28.7  cm. ;  average  upper  antero-posterior  diameter, 
16.9  cm.;  average  middle  antero-posterior  diameter,  15.67  cm. 
In  the  positive  cases  the  average  corresponding  diameters  are : 


Upper  lateral 

.     23.85  cm 

Middle  lateral 

.     17.44   " 

Lower  lateral       ...... 

.     29.06   " 

Upper  antero-posterior       .... 

•     1703    " 

Middle  antero-posterior      .... 

.     14.26   " 

The  difference  between  the  upper  lateral  and  the  middle  late- 
ral in  the  negative  is  3.42  cm.,  or  14.4  per  cent.,  and  the  differ- 
ence between  the  upper  antero-posterior  and  middle  antero- 
posterior is  1.23  cm.,  or  7.28  per  cent.,  while  the  difference 
between  the  upper  and  middle  laterals  in  the  positives  is  6.41 
cm.,  or  27  per  cent.,  and  between  the  upper  and  middle  antero- 
posterior 3.04  cm.,  or  17.5  per  cent.  This  shows  that  the  mid- 
dle zone  diminishes  in  size  from  above  downward  nearly  100 
per  cent,  more  from  side  to  side,  and  140  per  cent,  more  from 


MOVABLE     KIDNEY.  46/ 

before  backward  in  the  positive  cases  than  it  does  in  the  nega- 
tive. 

If  we  compare  corresponding  diameters  in  the  two  classes  of 
cases  we  find  that  the  upper  laterals  are  practically  the  same, 
while  the  positive  middle  lateral  is  2.76  cm.,  or  13.6  per  cent, 
smaller  than  the  negative.  In  the  upper  antero-posterior  there 
is  a  slight  increase,  2.3  per  cent.,  in  favor  of  the  positive,  and 
in  the  middle  antero-posterior  a  diminution  of  1.41  cm.,  or  9 
per  cent.,  in  favor  of  the  positive.  If  we  figure  the  area  of  the 
lower  end  of  the  middle  zone  we  find  that  it  is  21  per  cent, 
smaller  in  the  positive  cases  than  it  is  in  the  negative.  This 
diminution  in  size  is  equivalent  to  displacing  downward  the 
contents  of  this  space  2.6  cm.  at  its  lower  end. 

It  will  thus  be  seen  that  these  measurements,  however  figured, 
demonstrate  beyond  dispute  that  in  those  cases  in  which  we 
find  movable  kidneys  there  is  a  marked  diminution  in  the 
capacity  of  the  middle  zone  in  which  the  major  portion  of  the 
kidney  should  lie,  and  that  this  diminution  increases  in  ratio 
from  above  downward. 

As  the  chief  and  characteristic  peculiarity  of  these  cases  lies  in 
the  marked  difference  in  size  between  the  upper  and  lower  ends 
of  the  middle  zones,  the  ratio  which  the  one  bears  to  the  other 
may  be  used  as  an  index  to  express  the  particular  body-form  ; 
the  ratio  of  the  areas  would  be  the  more  correct.  However,  as 
it  requires  considerable  figuring  to  determine  this,  it  has  been 
found  much  simpler  to  use  the  ratio  of  the  middle  lateral  diam- 
eter to  that  of  the  upper  lateral.  It  corresponds  very  closely 
to  the  ratio  of  the  areas,  and  is  determined  by  dividing  the 
middle  lateral  by  the  upper  lateral  diameter  and  multiplying  by 
100.  This  constitutes  what  I  have  called  "  Index  No.  2,"  and 
is  more  reliable  than  "  Index  No.  i."  The  average  Index  No.  2 
for  the  negative  cases  is  85.26  and  for  the  positive  73.23. 

In  consulting  the  tables  we  find  that  all  cases  with  an  index 
above  81.8  are  negatives,  and  all  below  this  number  are  positive. 
We  find  in  the  table  two  cases,  Nos.  100  and  121,  with  the  same 
index,  namely,  81.8,  one  of  which  is  positive  and  the  other  neg- 
ative.      In  looking  at  the  antero-posterior  diameters,  however, 


468  HARRIS, 

we  find  a  contraction  of  from  18  to  14  or  22  per  cent,  in  the 
positive,  and  only  from  17  to  16  or  6  per  cent,  in  the  negative, 
which  explains  the  difference  very  nicely.  Had  the  areas  been 
used,  instead  of  simply  the  lateral  diameters,  the  indices  would 
not  have  been  the  same.  These  two  cases  also  illustrate  the 
fact  that  while  the  index  represents  briefly  and  in  a  general 
way  the  body-form,  it  does  not  take  into  consideration  all  the 
points,  and  is,  therefore,  not  entirely  reliable.  If  all  the  meas- 
urements be  considered,  and  particularly  the  five  taken  with  the 
calipers,  a  formula  will  be  obtained  which  represents  accurately 
the  body-form. 

Case  No.  98  shows  an  error  which  may  arise  in  measuring 
the  circumference  and  relying  on  Index  No.  i.  In  this  case 
the  deposit  of  fat  above  the  hips  was  very  marked  and  the  cir- 
cumference correspondingly  large.  This  gave  a  low  Index  No. 
I,  namely,  TZ-l^  which  should  indicate  a  negative  case.  The 
right  kidney,  however,  was  very  easily  found  and  freely  mova- 
ble to  the  second  degree.  If  we  consider  the  diameters  as  taken 
by  the  calipers,  which  eliminate  the  error  of  fat,  we  find  the  mid- 
dle zone  contracted  from  28  cm.  above  to  20  below,  a  difference 
of  nearly  28  per  cent.,  and  explains  at  once  the  cause  of  the 
movable  kidney.  Other  apparent  exceptions  are  thus  readily 
explained  when  all  the  measurements  are  taken  into  consider- 
ation. 

In  what  manner  does  a  diminution  of  the  capacity  of  the  mid- 
dle zone  bring  about  a  movable  kidney?  As  already  shown, 
the  upper  zone  remains  on  the  average  practically  the  same  in 
the  two  classes  of  cases.  Any  lessening  of  the  capacity  of  the 
middle  zone  must,  therefore,  result  in  a  displacement  of  the  con- 
tents of  this  space  downward.  The  liver  is  affected  first,  and  as 
it  is  depressed  its  posterior  border  acts  immediately  upon  the 
right  kidney,  tending  to  displace  its  superior  pole  forward  or  to 
depress  the  entire  organ.  The  presence  of  the  liver  explains 
the  great  predominance  of  involvement  of  the  right  kidney.  The 
left  kidney  is  not  only  somewhat  more  firmly  fixed,  but  has 
pressing  upon  it  only  the  small  spleen  and  the  soft,  yielding 


MOVAULE     KIDNEY.  469 

Stomach.  Although  this  depression  of  the  kidney  is  always 
present  as  the  principal  determining  cause,  it  is  not  the  entire 
cause  of  movable  kidney.  The  kidney  is  so  far  depressed  that 
the  constricted  and  narrow  outlet,  as  it  may  be  called,  of  the 
middle  zone  is  above  the  centre  of  the  organ,  so  that  every 
movement  or  action  of  the  body  which  tends  to  still  further  con- 
tract this  outlet  by  adducting  the  lower  ribs  produces  pressure  on 
the  upper  portion  of  the  kidney  and  constantly  tends  to  press  it 
downward.  The  amount  or  degree  of  mobility  depends,  there- 
fore, not  alone  on  the  amount  of  constriction  of  the  middle  zone, 
but  on  the  many  conditions,  such  as  heavy  lifting,  hard  work, 
straining,  coughing,  flexions  of  the  body,  etc.,  which  act  more 
or  less  continuously  by  pressing  the  organ  downward. 

These  various  influences,  which  are  quite  numerous  and  so 
well  understood  that  they  need  not  be  further  detailed,  may  be 
summed  up  under  the  term  "  internal  traumata."  As  they 
may  vary  considerably  in  different  individuals,  they  offer  a 
ready  explanation  of  the  fact  that  different  degrees  of  mobility 
may  be  present  in  individuals  of  practically  the  same  body- 
form. 

It  may  be  well  now  to  analyze  our  table  of  women  as  to  the 
etiological  influence  of  other  factors.  Measurements  were  made 
of  126  women.  No  attempt  was  made  to  select  these  cases, 
except  excessively  fleshy  women,  in  whom  nothing  within  the 
abdomen  can  be  distinguished  by  palpation  were  excluded. 
They  were  examined  as  the  occasion  presented  itself,  regardless 
of  whether  symptoms  were  complained  of  or  not. 

Of  the  126  women,  71,  or  a  little  over  56  per  cent.,  were  found 
to  have  distinctly  palpable  or  movable  kidneys.  Of  the  7 1  cases,  in 
35,  or  50  per  cent.,  the  left  kidney  was  also  palpable  or  movable, 
but  seldom  to  the  same  degree  as  the  right.  In  only  one  case 
was  the  left  alone  movable,  and  in  this  case,  although  the  abdo- 
men was  very  lax  and  easily  palpable,  no  evidence  of  a  right 
kidney  could  anywhere  be  felt.  Eighty-one  of  the  cases  were 
married  and  43  single;  2  not  stated.  Of  the  81  married  women, 
41,  or  50-f  per  cent.,  and  of  the  43  single  women,  28,  or  654- 


470 


HARRIS, 


per  cent.,  had  movable   kidneys.     Concerning   the  number  of 
children  born,  the  negative  cases  show  that 


6  had 

o  children. 

4     " 

I  child 

= 

4 

children 

3     " 

2  children 

= 

6 

3     " 

3 

= 

9 

3     " 

4 

= 

12 

4     " 

5 

= 

20 

I     " 

8 

= 

8 

I     " 

II 

= 

II 

5  women  had 

= 

70 

or  an  average  of  2.8  children  to  each  woman.       In  12  cases  the 
number  of  children  was  not  known.     Of  the  positive  cases  : 


6  had 

0  children. 

2 

I  child 

= 

2 

children 

10 

2  children 

= 

20 

4 

3 

= 

12 

4 

4 

= 

16 

2 

6 

= 

12 

I 

7 

= 

7 

I     " 

10 

= 

10 

30  w 

fomen  had 

= 

79 

children 

or  an  average  of  2.6  children  to  each  woman.  In  12  cases  the 
number  of  children  was  not  known. 

These  facts  point  to  the  conclusion  that  child-bearing  does 
not  produce  movable  kidney  and  has  no  influence  in  that  direc- 
tion in  the  absence  of  the  particular  body-form.  That  repeated 
pregnancies,  by  producing  relaxation  of  the  abdominal  walls 
and  deterioration  of  the  general  health,  may  induce  symptoms 
or  aggravate  those  already  present  is  very  probable,  and  will 
be  admitted.  The  same  may  be  said  concerning  lacerations  of 
the  perineum  and  displacements  of  the  uterus.  In  three  of  the 
negative  cases  complete  procidentia  was  present.  In  one  of 
the  positive  cases  there  was  complete  procidentia,  and  in  one 
prolapsus,  v/ith  rectocele  and  vesicocele. 

A  most  important  question  in  this  connection  is  the  possi- 
bility of  producing  a  movable  kidney  by  external  violence,  such 
as  a  fall  or  a  blow,  or  injury  in  the  region  of  the  kidney.     The 


MO  VA  BLE     K  I  DN  KY.  4/1 

importance  of  this  question  from  a  medico-legal  stand-point 
makes  it  necessary  to  enter  into  it  somewhat  in  detail.  It  is 
usually  stated  in  text-books,  and  it  is  a  common  belief,  that 
movable  kidneys  are  frequently  the  result  of  an  injury.  This  is 
but  another  of  the  numerous  post  hoc  propter  hoc  errors.  An 
individual  falls  or  meets  with  an  accident  in  which  the  body  is 
bruised  or  injured  in  some  manner,  and  an  examination  some- 
time thereafter  reveals  the  presence  of  a  movable  kidney.  It  is 
immediately  concluded  that  the  accident  bears  a  causal  relation 
to  the  movable  kidney,  without  stopping  to  consider  whether 
the  movable  kidney  may  not  have  been  present  long  before  the 
accident,  and  in  no  manner  influenced  thereby.  Several  facts 
have  contributed  in  giving  origin  to  this  belief.  First  may  be 
mentioned  the  fact  that  the  large  majority  of  physicians  are  still 
unfamiliar  with  the  great  frequency  of  movable  kidney  in  women. 
A  physician  of  considerable  experience  recently  stated  it  was  a 
very  rare  condition,  and  in  all  his  experience  he  had  seen  but 
four  cases. 

Secondly,  in  many  cases  movable  kidney  gives  rise  to  no 
appreciable  symptoms,  and  in  a  large  majority  of  those  in  whom 
distinct  symptoms  are  undoubtedly  due  to  the  movable  kidney 
the  patients  themselves  are  unaware  of  the  cause  of  their  symp- 
toms, and  often,  unfortunately,  the  attending  physician  as  well. 

Thirdly,  there  is  no  means  of  determining  how  long  a  kidney 
has  been  movable. 

For  the  same  reasons  many  writers  on  this  subject  have  over- 
estimated the  causal  influence  of  trauma.  Most  of  the  cases 
recorded  as  due  to  trauma  will  not  stand  criticism.  Sulzer,'  in 
regard  to  this  relation,  says  :  "  However,  one  will  have  to  be  very 
careful  in  judging  of  these  very  relations,  for,  on  the  one  hand, 
we  know  from  other  diseases  how  readily  people  in  general  refer 
their  troubles  to  a  particular  injury,  and  on  the  other  hand,  we 
shall  see  later  that  upon  the  occasion  of  a  fall  or  exertion,  etc.,  a 
movable  kidney  which  is  already  present,  may  suddenly  present 
severe  so-called  strangulation  symptoms,  and  thus  become  first 

»  Deufsch  Zeits.  f.  Chir.,  1891,  Bd.  xxxi.,  S.  506. 


472  HARRIS, 

known  to  the  patient  or  physician  after  it  has  existed  without 
symptoms  for  months  or  years,"  After  considering  the  anatomi- 
cal fact  of  the  looseness  of  the  peritoneum  covering  a  movable 
kidney,  he  says  :  "  The  acute  origin  of  a  movable  kidney,  if  it 
occur  at  all,  is  then  only  possible  when,  owing  to  a  congenital  or 
acquired  looseness  of  the  peritoneum,  the  disposition  to  the 
trouble  already  exists."  He  further  states:  "The  question 
whether  an  acute  traumatic  origin  of  a  movable  kidney  be  pos- 
sible may  be  very  important  in  a  medico-legal  relation  or  in 
insurance  business,  and  I  believe  that  without  the  acceptance  of 
a  particular  abnormal  body  condition,  a  movable  kidney  can 
never  be  the  immediate  result  of  a  trauma."  Sulzer  arrived  at 
these  conclusions  after  a  study  of  the  cases  in  which  a  movable 
kidney  was  supposed  to  have  resulted  from  an  accident,  and 
owing  to  the  fact  that  the  peritoneum  which  covers  the  kidney 
in  front  and  aids  in  holding  it  in  place,  is  very  much  relaxed  in 
movable  kidney,  and  this  relaxation  or  pouching  is  so  great  that 
it  cannot  be  produced  suddenly  any  more  than  a  large  hernial 
sac  can  be  produced  suddenly.  Keller^  is  also  of  the  opinion 
that  this  condition  cannot  be  produced  suddenly,  but  requires  a 
considerable  time  for  its  development,  and,  therefore,  a  kidney 
with  a  distinct  range  of  motion  discovered  immediately  or  soon 
after  the  receipt  of  an  injury  must  have  been  movable  before, 
and  its  mobility  cannot  thus  have  been  caused  by  the  injury. 

Concerning  the  traumatic  origin  of  movable  kidney,  Biidin- 
ger  says  :^  "  When  the  kidney  is  fixed  they  (traumata)  are 
able  to  produce  only  the  first  step,  while  the  formation  of  the 
typical  movable  kidney  requires  still  other  conditions.  A 
sudden  marked  dislocation  presupposes  an  extensive  loosen- 
ing of  the  kidney,  and  not  onl)'  that,  but  a  space  below  the 
kidney,  with  a  considerable  change  in  the  relations  of  the 
peritoneum." 

Giiterbock^  concludes,  from  a  study  of  injuries  to  the  kidney, 
"  that  a  typical  movable    kidney  does    not   occur   as  a  result 


1  Deutsch  Chir.,  I.ief  67. 

'  Mittheil.  aus  d.  Grenzgebiet,  1898-99,  No.  4,  S.  265.  '  Quoted  by  Biidinger. 


MOVABLE    KIDNEY.  473 

of  trauma,  but  only  a  loosening  of  the  organ,  which  later 
may  lead  to  mobilization  unless  the  kidney  becomes  fixed  by 
adhesions.  But  even  if  one  disregards  the  demand  that  a 
traumatic  movable  kidney  must  show  relations  analogous  to 
the  anatomical  findings  of  the  classical  movable  kidney,  the 
number  of  such  cases  is  very  small  in  which,  in  the  living 
subject,  a  connection  between  the  injury  and  the  mobility  with 
certainty  can  be  demonstrated.  The  pain  in  a  movable  kidney, 
which  is  discovered  immediately  after  an  accident,  is  not  the 
slightest  proof  of  any  connection  between  the  accident  and 
the  movable  kidney,  nor  are  all  the  other  subjective  symptoms 
of  any  proof  so  long  as  it  cannot  be  demonstrated  with 
unequivocal  certainty  that  the  kidney  before  that  time  was  not 
movable." 

A  simple  fall  is  insufficient  to  give  rise  to  a  movable  kidney 
in  the  presence  of  normal  relations.  The  injury  must  be  severe 
enough  to  produce  a  rupture  or  laceration  of  the  tissues  which 
normally  surround  and  fix  the  organ,  in  which  case  symptoms 
sufficiently  marked  to  direct  attention  to  the  nature  of  the 
injury  will  always  be  present.  The  kinds  of  injuries  most 
liable  to  produce  such  lacerations  are: 

1.  Severe  falls  upon  the  buttocks  in  a  sitting  position. 

2.  The  body  is  thrown  violently  against  some  object,  striking 
the  region  of  the  kidney  so  as  to  forcibly  adduct  the  lower  or 
loose  ribs.  The  same  effect  is  produced  if  the  object  be 
movable  and  the  body  stationary. 

3.  This  region  of  the  body  is  compressed  between  two  oppos- 
ing forces.  Such  injuries  may  produce  lacerations  of  the  peri- 
renal adipose  tissue, with  the  formation  of  a  perirenal  haematoma, 
which  may  vary  much  in  size.  These  haematomata  are  retro- 
peritoneal, and  it  is  the  exception  when  the  peritoneum  is  torn. 
Symptoms  of  sufficient  severity  to  direct  immediate  attention 
to  the  region  of  the  kidney  are  always  present  in  case  of 
laceration  with  the  formation  of  a  hnsmatoma  of  any  material 
size.  The  swelling  produced  by  the  h;tmatoma  may  also  be 
usually  felt  on  palpation,  although  the  tenderness  may  be 
so    severe    as    to    interfere    in    this   direction.     Accompanying 


474  HARRIS, 

the  absorption  of  such  a  haematoma  an  increased  amount 
of  connective  tissue  usually  forms  in  the  adipose  capsule, 
which  may  fix  the  kidney  more  firmly  than  before.  On  the 
other  hand,  the  haematoma  may  dissect  up  the  perirenal  fat,  or 
lead  to  the  formation  of  a  perirenal  serous  cyst,  in  the  loose 
space  of  which  the  kidney  may  move  about,  and  thus  an  injury 
may  be  the  direct  cause  of  a  movable  kidney. 

The  symptoms  which  immediately  follow  the  injury  will 
direct  attention  to  this  possibility,  but  such  cases  are  rare.  Of 
course,  an  injury  may  produce  a  laceration  of  the  kidney  proper 
without  the  formation  of  a  perirenal  haematoma,  or  the  two 
conditions  may  exist.  When  the  kidney  substance  is  lacerated, 
or  the  pelvis  opened,  the  presence  of  h^ematuria  will  direct 
attention  to  the  fact. 

It  should  be  remembered  that  in  the  presence  of  a  movable 
kidney  a  slight  injury,  such  as  a  fall,  or  jarring  of  the  body,  or 
straining  at  lifting,  may  produce  a  slight  haematuria  for  a  few 
days,  without  the  occurrence  of  a  material  lesion  in  the  kidney, 
and  without  other  symptoms  particularly  referable  to  this 
organ.  In  fact,  this  is  so  common  that  the  presence  of  such  a 
haematuria  following  a  slight  injury  should  at  once  suggest  the 
possibility  of  a  movable  kidney,  and  lead  to  an  examination 
with  this  point  in  view.  The  more  often  such  examinations 
are  made  immediately  following  such  injuries,  the  less  often  it 
will  be  found  that  the  injury  had  aught  to  do  with  causing  the 
movable  kidney. 

The  fact  that  a  movable  kidney  is  surrounded  by  a  loose  peri- 
toneal and  connective  tissue  pouch,  which  must  necessarily  be  of 
slow  formation,  precludes  the  possibility  of  a  movable  kidney 
being  produced  suddenly  by  an  injury.  It  is  in  just  this  class 
of  cases  that  the  value  of  correctly  estimating  the  body-form 
by  the  measurements  as  herein  mentioned  is  so  apparent.  Thus 
if  a  woman  with  an  unmistakable  body-form  of  the  positive 
type  present  herself  with  a  movable  kidney  which  is  said  to 
have  followed  an  injury,  it  may  with  practical  certainty  be 
asserted  that  the  movable  kidney  is  the  result  of  the  body-form, 
and  arose   independently  of  the  injury.     The  injury  but   calls 


MOVABLE     KIDNEY.  475 

attention  to  a  condition  already  present,  but  perhaps  unrecog- 
nized. Of  course,  it  is  not  denied  that  a  movable  kidney  may 
be  aggravated  by  an  injury,  or  that  such  a  kidney  may  be 
injured  by  external  violence  as  well  as  a  kidney  that  is  fixed 

Of  the  cases  comprising  the  table  there  were  two  belonging 
to  the  negative  tj'pe  in  which  a  history  of  an  accident,  such  as 
might  have  injured  a  kidney,  was  present,  but  in  none  of  these 
could  the  kidney  be  felt. 

Of  the  positive  cases,  7  gave  the  history  of  a  fall  or  other 
injury.  One,  No.  70,  was  not  aware  that  she  had  a  movable 
kidney,  but  gave  a  history  of  unmistakable  symptoms  referable 
to  the  urinary  organs  and  stomach  which  antedated  the  injury, 
thus  clearly  eliminating  the  injury  as  a  causal  factor  in  the 
movable  kidney. 

In  Case  No.  1 10  the  injury,  a  jarring  of  the  back,  was  claimed 
as  the  cause  of  the  movable  kidney.  She  was  examined  within 
a  month  after  the  injury,  when  the  kidney  was  found  so  freely 
movable  and  so  devoid  of  tenderness,  and  the  injury  was  so 
slight,  as  to  preclude  the  possibility  of  a  causal  connection. 

Case  No.  42  had  a  fall,  injuring  the  knee,  but  the  region  of 
the  kidney  was  not  involved,  and  the  presence  of  the  movable 
kidney  not  suspected. 

In  Case  No.  59  the  injury  was  undoubtedly  instrumental  in 
producing  the  mobility  of  the  left  kidney.  The  right  kidney 
was  also  very  movable,  but  this  was  an  old  condition.  Follow- 
ing a  rather  severe  injury  to  the  left  side,  in  which  the  left 
tenth  rib  was  fractured,  there  developed  a  large  swelling, 
haematoma,  about  the  left  kidney,  which  was  very  painful,  was 
accompanied  by  haematuria,  and  confined  the  patient  to  bed 
for  several  weeks.  The  swelling  was  several  months  in  dis- 
appearing, and  a  year  after  the  accident  the  kidney  was  still 
somewhat  enlarged,  tender,  and  movable.  In  this  case  there 
was  •  no  question  as  to  the  injury  to  the  kidney  and  its 
surroundings. 

In  Case  No.  37  it  was  first  thought  that  the  injury  bore  a 
causal  relation  to  the  movable  kidney.  A  chair  was  removed 
from  behind  the  patient  as  she  was  about  to  sit  down.     She  sat 


476  HARRIS, 

down  on  the  floor  very  heavily.  Considerable  pain  and  tender- 
ness in  the  right  side  with  light  fever  followed  for  some  time. 
The  tenderness  was  so  limited  to  the  region  of  the  caecum  that 
chronic  appendicitis  was  diagnosed.  Some  two  months  later 
the  appendix  was  removed.  It  was  not  found  to  be  directly 
involved,  but  recent  adhesions  were  found  between  the  caecum 
and  ascending  colon  and  the  abdominal  wall.  Six  months  later 
the  patient  returned,  still  complaining  of  pain  in  the  back  and 
right  side.  The  freely  movable  kidney  was  now  recognized  and 
nephrorrhaphy  performed,  with  relief  from  the  symptoms.  It 
seems  more  probable,  after  reviewing  this  case,  with  the  knowl- 
edge furnished  by  the  two  operations,  that  the  kidney  was  mov- 
able at  the  time  of  the  fall,  and  that  the  sudden  motion  given 
to  it  by  the  fall  produced  the  mild  traumatic  peritonitis  about 
the  caicum  and  colon  which  produced  the  symptoms.  At  the 
operation  on  the  kidney  there  were  no  evidences  found  of  an 
old  haematoma,  nor  of  unusual  formation  of  connective  tissue. 

In  Case  No.  1 14  the  injury,  a  fall  from  a  tree,  occurred  twenty 
years  ago,  and  the  history  was  too  indefinite  and  remote  to  be 
considered  at  this  date. 

Case  No.  35  was  a  poor,  hard-working  woman,  with  a  pen- 
dulous abdomen  and  marked  visceral  ptosis.  A  year  and  a  half 
before,  she  fell  on  her  side  and  hips  on  the  street.  Both  kid- 
neys were  movable  to  the  second  degree,  and  it  was  claimed 
that  the  fall  was  responsible  for  this  condition.  The  fall,  how- 
ever, was  not  a  severe  one ;  no  complaint  was  made  at  the  time 
of  any  trouble  in  the  region  of  the  kidneys;  the  pendulous 
abdomen  and  visceral  ptosis  were  present  for  a  long  time  before 
the  fall.  It  is  more  than  probable,  therefore,  that  the  kidneys 
were  movable  at  the  time  of  the  fall,  and  that  the  injury  had  no 
effect  whatever  on  them.  Thus  of  the  7  cases  in  only  i  had 
the  injury  any  causal  relation  to  the  movable  kidney,  and  in  this 
case  a  material  lesion  in  the  shape  of  a  large  perirenal  h;uma- 
toma  was  present,  which  was  distinctly  recognized  at  the  time 
and  which  produced  severe  symptoms,  confining  the  patient  for 
several  weeks  to  bed. 

Based  upon  these  facts  it  may  be  concluded  that  the  popular 


MOVABLE    KIDNEY.  47/ 

belief  in  the  traumatic  origin  of  movable  kidney  is  not  sup- 
ported by  the  evidence,  and  that  it  is  highly  improbable  that  a 
single  injury,  such  as  a  fall,  which  does  not  produce  a  material 
lesion  of  the  perirenal  tissues,  recognizable  by  well-defined 
symptoms,  is  ever  the  immediate  cause  of  a  movable  kidney. 

It  would  be  of  considerable  interest  to  know  at  what  age  or 
period  of  life  the  body-form  becomes  established,  and  how  soon 
it  influences  the  location  of  the  kidney.  I  have  not  sufficient 
data  at  present  upon  which  to  base  an  opinion  on  this  point, 
and  it  can  only  be  determined  after  a  systematic  examination  of 
a  large  number  of  individuals  during  the  developmental  period. 

The  measurements  of  a  number  of  children  are  contained  in 
the  table,  but  the  number  is  too  small  to  permit  of  an  analysis. 
It  is  evident,  however,  that  in  early  childhood  there  is  no  mate- 
rial difference  in  the  body-form  of  the  two  sexes.  The  number 
of  men  upon  whom  measurements  have  been  made  is  also  too 
small  to  establish  normal  averages,  and  as  there  was  but  one 
case  of  movable  kidney  in  the  number  no  differences  can  be 
drawn  between  the  negative  and  positive  cases.  The  measure- 
ments taken,  however,  show  that  the  lower  zone  is  much  smaller 
than  in  women,  while  the  middle  and  upper  zones  are  larger. 
The  increased  size  of  the  middle  zone  is  particularly  suggestive, 
inasmuch  as  movable  kidney  is  so  rare  in  men  compared  with 
women.  The  tendency  is  to  a  low  Index,  No.  i,  and  a  high 
Index,  No.  2,  which  is  characteristic  of  the  negative  body-form. 
The  man  in  whom  the  movable  kidney  was  found  had  had  two 
or  three  severe  falls  of  several  feet,  one  of  which  was  followed 
by  haematuria  and  distinct  evidences  of  a  lesion  of  the  kidney. 

Stiller  has  somewhat  recently  called  attention  to  the  associa- 
tion of  a  loose  or  floating  tenth  rib  and  movable  kidney.  He 
claimed  the  association  was  so  constant  as  to  establish  a  rela- 
tion between  the  two,  and  a  floating  tenth  rib  was  therefore 
called  the  "Stiller  stigma,"  or  the  Stiller  sign  of  a  movable 
kidney. 

The  condition  of  the  tenth  rib  was  noted  in  1 10  of  my  cases, 
49  of  which  were  negative  and  61  positive.  Of  the  negative 
cases  the  tenth  rib  was  found  loose  in  26  and  fixed  in  23.     In 


4/8  HAKRI3, 

the  positive  it  was  loose  in  38,  fixed  in  22,  and  in  i  case  both  the 
ninth  and  tenth  were  loose.  By  the  term  "loose"  is  not  neces- 
sarily meant  absolutely  free  and  floating,  as  are  the  eleventh  and 
twelfth  ribs,  as  this  condition  is  not  common,  but  in  case  the  at- 
tachment of  the  rib  to  the  costal  arch  was  so  slight  as  to  permit 
considerable  free  motion  independent  of  the  costal  arch  it  was 
said  to  be  "  loose."  In  case  the  attachment  was  so  firm  as  to  pre- 
vent any  material  independent  motion  it  was  said  to  be  "  fixed." 
From  my  examinations,  therefore,  Stiller's  observations  can- 
not be  confirmed.  While  a  loose  tenth  rib  is  the  rule  in  women, 
it  bears  no  definite  relation  to  the  presence  or  absence  of  a 
movable  kidney. 

The  contraction  of  the  middle  zone  explains  the  great  fre- 
quency with  which  the  so  called  vertical  stomach  is  associated 
with  movable  kidney,  as  the  pylorus  and  upper  duodenum  de- 
scend more  or  less  with  the  kidney,  while  the  cardia  remains 
fixed  by  the  oesophagus. 

It  is  not  the  intention  to  discuss  the  clinical  aspect  of  mov- 
able kidney,  hence  the  symptomatology,  diagnosis,  etc.,  will  be 
passed  without  further  remarks. 

Concerning  the  treatment,  attention  will  be  briefly  directed 
only  to  the  method  of  operating,  but  it  is  not  to  be  understood 
by  this  that  it  is  necessary  to  operate  all  cases,  as  such  is  far 
from  being  the  case.  However,  when  it  is  decided  that  the 
symptoms  with  which  a  patient  suffers  are  due  to  the  movable 
kidney,  there  is  little  reason  to  hope  for  permanent  relief  by  any 
other  method  than  that  of  operative  fixation  of  the  organ.  The 
tendency  in  recent  times  has  been  to  fix  the  kidney  too  high  up, 
apparently  from  the  idea  that  the  disturbances  were  due  rather 
to  the  fact  that  the  kidney  was  too  low  than  that  it  was  too 
freely  movable.  If  the  points  brought  out  in  this  contribution 
are  correct,  the  descent  of  the  kidney  has  been  brought  about 
by  the  fact  that  the  middle  zone  of  the  body  cavity,  in  which 
the  major  portion  of  this  organ  normally  should  lie,  is  too  small 
to  contain  it.  It  would,  therefore,  appear  unreasonable  to  at- 
tempt to  fix  the  kidney  in  a  cavity  too  small  for  it  and  from 
which  it  had  been  ejected. 


MOVABLE    KIDNEY.  479 

Should  this  be  done,  however,  the  same  factors  which  caused 
the  kidney  to  become  movable  in  the  first  place  are  again 
brought  into  action,  with  the  probabilities  of  a  recurrence.  Or 
should  the  kidney  be  so  firmly  fixed  in  a  high  position  that  it 
cannot  again  be  displaced,  symptoms  even  more  severe  than 
those  for  which  the  operation  was  undertaken  may  result.  The 
author  has  recently  seen  two  such  cases  operated  by  most  excel- 
lent surgeons,  one  in  Chicago  and  the  other  in  New  York,  with 
perfect  operative  result.  The  kidneys  were  high  and  firmly 
fixed,  yet  both  cases  suffered  infinitely  more  after  the  operation 
than  they  did  before,  and  in  one  case  the  suffering  became  so 
intense  that  about  two  years  after  the  first  operation  relief  was 
obtained  by  removing  the  kidney  entirely. 

The  principle,  then,  that  should  guide  us  in  fixing  a  movable 
kidney  is  to  take  into  consideration  the  body-form  and  fix  the 
organ  in  a  location  where  it  will  not  again  .be  subjected  to  the 
same  influences  which  caused  its  descent.  This  means  that  the 
kidney  should  not  be  crowded  up  to  the  highest  point,  but  fixed 
lower  down  in  an  easy  position,  and  so  the  ureter  will  escape 
at  the  most  dependent  part.  If  this  be  done  the  chief  cause 
of  relapse  will  be  removed.  The  method  of  operating  is  as 
follows  : 

A  muscle-splitting  incision  is  made,  beginning  a  little  in  front 
of  the  tip  of  the  twelfth  rib  and  extending  downward,  forward, 
and  inward  in  the  line  of  the  fibres  of  the  external  oblique 
muscle.  These  are  separated  bluntly,  and  then  the  fibres  of  the 
internal  oblique  and  transversalis,  which  cross  the  line  of  incision 
at  almost  a  right  angle,  are  separated  in  the  same  manner. 
The  peritoneum  is  carried  inward  and  the  perirenal  space  en- 
tered. All  the  perirenal  fat  is  removed,  but  the  perirenal  fascia 
is  carefully  preserved.  The  upper  portion  of  the  ureter  should 
be  examined  to  see  that  it  is  not  fixed,  and  thus  become  flexed 
or  kinked  by  moving  the  kidney.  The  perirenal  fascia  with  the 
peritoneum  covering  in,  and  to  which  it  is  usually  quite  firmly 
attached  throughout  its  anterior  and  inner  portions,  forms  the 
pouch  or  sac  in  which  the  kidney  moves.  This  space,  bounded 
by  the  perirenal  and  retrorenal  fasciae,  sometimes  called  Gerotta's 


480  HARRIS, 

space,  is  somewhat  triangular  in  shape,  with  its  apex  extending 
downward  toward  the  brim  of  the  pelvis. 

The  object  of  the  operation  now  is  to  so  close  this  space  and 
contract  the  pouch  or  sac  that  the  kidney  will  no  longer  have  a 
free  space  in  which  to  move.  This  is  accomplished  by  closing 
this  space  from  before  backward  with  catgut  sutures.  The  colon 
lies  just  anterior  to  this  space,  and  should  not  be  injured.  Should 
the  pouch  in  which  the  kidney  moves  be  very  large  and  bulge 
the  peritoneum  to  the  inner  side  of  the  colon,  a  small  opening 
may  be  made  into  the  peritoneal  cavity  just  to  the  outer  side  of 
the  colon,  and  the  sutures  passed  through  the  mesocolon  from 
within,  thus  approximating  this  layer  to  the  posterior  abdominal 
wall  and  obliterating  or  diminishing  the  pouch.  By  passing  the 
sutures  in  this  manner  the  danger  of  including  in  them  the  colica 
dextra  or  sinistra  artery,  as  the  case  may  be,  is  avoided.  The 
branches  of  the  lumbar  plexus  of  nerves  on  the  posterior  wall 
should  also  be  remembered,  and  care  taken  not  to  include  them 
in  the  sutures. 

The  effect  of  suturing  in  this  manner  is  to  obliterate  the  space 
in  which  the  kidney  has  been  moving  up  and  down.  The  outer 
edge  of  the  perirenal  fascia  is  then  sutured  to  the  lumber  fascia, 
posterior  to  the  line  of  incision  through  the  walls.  By  drawing 
more  on  the  upper  or  lower  portion  of  the  fascia  the  kidney  may  be 
rotated  on  its  antero-posterior  axis,  as  may  be  necessary  in  order 
to  bring  the  ureter  at  a  proper  dependent  position.  When  the 
operation  is  finished  the  kidney  will  be  found  firmly  held  in 
position,  yet  not  so  fixed  that  it  cannot  move  up  and  down 
slightly,  as  a  normal  kidney  should  during  respiration.  All 
abnormal  excursions  of  the  kidney,  however,  are  completely 
arrested,  although  the  organ  occupies  a  lower  position  than 
normal.  No  stitches  involve  the  kidney  substance.  This  oper- 
ation was  not  of  sudden  birth,  but  of  gradual  development  dur- 
ing the  past  three  or  four  years.  Clinically  the  results  have 
been  good,  and  in  patients  examined  as  long  as  two  years  after 
the  operation  the  kidney  has  been  found  still  in  the  location  in 
which  it  was  fixed  and  without  any  increase  in  its  range  of 
motion.     In  closing,  the  following  conclusions  are  presented  : 


-o 

0      ;,;           . 

1 

•2              -cWg-sS  .2 

a                      3      -•-—     ■»» 

11  develo 

[bloody 
fell  6  ft. 
ender,  cl 
[append 
er  and  sp 

ppendici 

0                                   Q  <n       >       0 

^                       S<i,-    -    .2.a 

X 

ration, 
ambler, 

eration. 

cs ;  in  1 
movabl 

n!arged 

Chron 
stomac 

< 
S 

m 

li      s  H  "  f1 

« 

.2   •-•S              .2   .S  3    s    £  2 

.-  .liS           .-s   a-^    s   «e 

pendic 

pendic 
Profe 

pendic 

8  ft.  0 
y  felt, 

3art  di 

Kapid 
Care 

nic  ap 

nic  ap 
C.  73. 

nic  ap 

82  fell 
kidne 

ularh 

thin, 
ciated 

0   ^►j        J   0   5 

;s  >  >w      1 

■jCenpjn  'jje'i 

9N- 

-  —  '^        1 

•X9apiJ[  it(8ia 

ii4Ba9x 

1 c-    .    .    .    .to    : 1 

•g-ON  xepni      ^ 

00    .    .■«    .    . 

■»■ 

1 

■qo    "    ■    ■    ■ 

1       00-»          towto 

c-M?: 

?;w      ccr-      c- 

t-.*-»ootom 

•I  -ON  xepni    „,i^^t-c;oc 

-H  — Ky 

TO  -f  C-  «.-  0  to  u- 

ir-  c-  tc  c-  t-  c-  r- 

totcoc  acooocc 

06 

HOT  noi^ipnoo  | 

Jfefe 

;jfe 

ft 

j>-i 

fe  ;^  ;j 

•aippini'  niBip  1 

•jsod-oaeiny  | 

J3  ■ 

1-1 

QO 

•joddn'^oiBirp  1 

•isod-ojeia'v  | 

oa    . 

2 

00     . 

Oi     . 

•aOAioj     1 

•taBip  XBja^Bq  | 

S    • 

eq 

a  • 

s  • 

•ejppim      1 

oiBip  {BjeiBq  1 

M     • 

li  ■ 

Cl     ■ 

•aaddn 

ira    . 

'mBip  '[BJSiBq 

s  • 

IT) 

§?    ■ 

^  • 

•euoz 

ir 

ITS                                                                IT 

0  ir 

1 

jaaioj   q-tSngq 

•eooz 

0  u^  in          m                                                  0 

qppiuiq^aaeT 

oc»rtcoa050co».oect^aoaocDt*i—  ^L-^t—  oooov  cDci-tt^oOii-f 

■eaoz  J8d 

»rt                           IfMit              ».'5                                 (.-5              0 

da  JO  q^Stjeq 

i-scDi/tcoooc^acoocOimct^ii^Jccoooooi/tocoioaot-w^cooicD 

•qdniXs  oja3af 

irriO'*tOtf5iO»/3irt»rai/^irtir3u?»f7inioio».cim/3irt»o».'Dmi.'?ir5»rt 

■qia  qfjoi 

10           irt                                                           if3 

(O98pej0Moi 

a>co:ooot-o>->*ioi;Deg'-iirtoiO(X)mco^^»HC»5M'<i<tD03Cc- 

>aa9J3jtnnoaio 

•raanja^a 

...                 <"       .^   .    .               .               ... 

lO    pn9J9AiO| 

S3<31     ■           'ooSjoSSoO     '00     ■ 

ujino    .  —  oeo    .00 

OOt^OO       000000     f~     * 

iOU9J9ja)RajlQ 

1           -irt 

M  M  g  15      •  ■*  0  to  Irt  30  t-  t-5 
t^D-OOtO      .CCOOC-C-t-C-t' 

1               1.C      mc-                                               .* 

•?q»F»AV|g«g;5gp,Sogpg5.  .30o^'  =  i«2g=2-^;gig  .3 

•aav  1  §JS^5?55S?iS??5^5?3':?5SS3Sg?8SJJ^-l5S2^?:? 

S 

.  I'm  .a  .  .  .f^a;  .  .^  .>  .  .  .  ;    f,  '-u^m  -S 

•4 

W  ^^  ^S:  ^wEiH'mwddfaaWufctii^'I^KPdK-riddcnE^ 

da^adafe',"jp''Hd>^a3&;d'Jtii2«fflo'a:cJ-3i-ia 

•J9qina(j 

- 

cm -4 

IT 

^t-« 

0»OjH« 

«•* 

S 

5DC-OC 

g 

5i?i? 

ags§= 

s 

1 

Remarks. 

Abdominal  wall  quite  lax. 

Abd.  wall  loose ;  Lac.  cervix  ;  u.  normal. 

•XoapiJj  rjj  jrj 

.-- 

•.?9ap!Ji  'jqSia 

z-  -■  '  * 

■     ■     -  ac  t— 

•2  -ON  xapni 

:  :s5 

•I  •  'M  xapni 

t- «  -  -^. 

to  -OtO-tZiZ 

JO  nompuo^  1  1-1^-       *-' 

•piui  ■•uiyjp      j     .    .    . 

agddn'-tuBip      1    •    • 
•jsod-joij9iav  1    •        SS 

■J9MOJ  'Ja49        1           • 
-tDBTp    JBI9'JB'-[  1                   W?) 

•9jp|nin'j9;9      1        ■    . 

-IDBip    lBJ94Bq;  1      •     .      IMM 

•J9ddn  'J9^9      1           • 
-cuBip  [Bjg^BT  1        ■    -teoN 

•9UOZ  JJMUI        1   ^. 

•9no2 
dippiai  q^jSaeq 

.-J  -^  -^:  in  •.* 

•enuz  j«d 
-dn  JO  qiSnoq 

S2si^s 

•ST9.?qd 
-in.?s  'o|n3nx> 

oc-i^.-o 

•qiJ  ^^XOl  JO 

<^3p9  J9A^O]4B 

3ou9J9jmnoJio 

gsgsirfgS 

•uinnj949  JO 

pU9   J9MOJ  4B 

aonejajmnojif) 

•qcoc"^'^ 

•iqSiOH 

•jqS!9.v\  1  gjc^ig 

:i,jp|iqo  JO  -OiSJ  1     .  — «^-""" 

JO  paijjBui  1  x-a- 

■eav  1  5i§ti?!SS 

Females. 

&4      ••      •      • 

•x-aitliHa; 

1            -joquinM 

""=^:$S 

1 

1 

J 

1 

«• 

H 

Ell 
11 

1 

\ 
1 

1 

r 

j 

ii 

^J  i  |l 
If  1^1 

IJII 

ill! 

■io.n>iiii»T 

oinnsajj yiKKx.1 

'Uip|>|lVi|H 

..!i»~» \^^ny.s   1 

■I  OS  Kpa, 

s   :::::.  jj    Ij ::    J ::    ; 

1 

■loSMP"! 

SS3Ssisl=!-SPB=ESSSgSS55S5i 

«;  J  %4 

".ffi?^,".^. 

a           ■        2    = 

-      ■ 

■iaMi-oj»i(iv 

:. 

:  ;  :  .  :s  : 

. 

:...;;: 

■mvip'iSl 

> 

:  :  :  :  :a  : 

B 

■«■--■■ 

mi..p"!S«J,1a 

■a 

::;::»: 

aioip-[»"liT 

a 

: : :  ■  E 

a 

jai!.ot  qiKoo^ 

a!l!!3aS22SS=a2S2!lEa=SSI!:SSS!=2 

dn  JO  qj»i»q 

22S22!:222S==2S=2SS2Sa2ES222 

qtHnXfloinSaf 

SSSSSSaS3aS3SS3aS3SJSS5KSSE 

,o^pn»»«pi^     SS  ;   ■  ;S3S=5S    S  ;    StSS    S3S    E!  •  ■ 

■)q»i9H  !:g  B*?cS?§??H3  ===§  ??SSuEE 

■iq»[OAi 

jjr-, ;;':,!!;:.    ■    -  ^^    .;'■  '•r'i-%    %    I 

5 

_'    -=  -' ' 

-     _^i»    B 

■           das 

a-.st-i-jt-t-^-x=3&. 

•-.rrSfioKoj^a 

■Jiqiaatl 

""'" 

-rwC 

;^ 

aciieisHS 

1 

i|ss=  III;  el  iiii;  -I 
itiit  silt  il  filil  SB 


Kaaaa  as  asaa  gaa  a 


as  aagas  a  a  aa     as 


m\  K  2tiaiii 


sasas:'  asaa  a  ssass  ass 


2_a  sj  aga2a  sieas  s 


-       z-  : 

„ 

5 

■^.-- 

J'-SsftE":  ;  :  ysr: 

-       ZiS 

s 

sss 

ss2='--sSs--- 

SS3 

s 

S 

2    S 

SS3S8S  ■     ■ 

-     aas 

s 

SKS 

Eisgsssasss^ 

:;:     sss 

S«S 

J     i:=  J 

>.'j>:^K.js  %:  Jt: 

g  aiissiiia0B_s|5^5Mii??-^?d.^As__ssK_^_8_MS. 


JsaasKSSs? 


sgassaaaaas        ^s£/t? 


SSSSTJg   a    $   _S5 A? 


SSPSS    E^P   SS3S    33S 


£ja  g  g  SS3  ssssaasssa 


sss  s  3  Res  ssesessssss 


?ang"^narn 

....... 

:::« 

■:- 

Si 

::= 

P     ;S  ; 

s 

a 

sa 

;- 

CB 

s; 

S      ;S 

s 

SSBS     • 

•  ? 

:-;:S 

: :  :^ 

i:- - 

=  s  s 

2 

"t 

iS  ■ 

:    -SS    ■  sss 

■iq»!8a 

iSSs  iiS  S 

SS 

as?i 

SS2 

» 

:§■ 

SIsiS 

B 

S 

■% 

SS 

a 

s  : 

S  S  : 

s 

as :  :a8 

;  1 

Egg    3 

sxgs 

2 

SSS£ 

K    g    8 

E 

is 

s3 

glgssglgjas 

■llSl^.tt 

sai^  SES?s 

SP 

S    SS 

ai8» 

S    2 

Rssas 

a 

» 

.^ 

SH 

aP5 

s 

8    SS 

s 

■SSBS  . 

gsss 

SS5  -S 

S     :    3 

f 

IT 

,_ 

«    K'JKJ=53 

^jpijqojocN 

xa^^    ■■■ii' 

■■■* 

■■*■■■■■ 

^1 

Jii. 

-    a: 

«• 

a:  -  =  «-a 

=  »=a' 

»ia=« 

a 

-■■■■■^■i 

^     »    = 

a 

■■J. 

a'-- 

Ma»a: :  oda*:  = 

— — ^ 

_GSrf«_^«e^«SL 

^"^^ 

^^^ 

— L 

■-•^^ 

-^ 

_ii_ 

"^ 

_s«_ 

^  " 

^^^^" 

^^"" 

^^=- 

^^^^^ 

'^    "    " 

-si. 

_JLi_ 

,j-i^ 

=s?ssssss  pspssass 


i^SS  SJ  s  gy^  s;?33^sst: 


SR    S    S    8;;      S5S    3S    SS    S    gS    3    yssSSS    5    S    SSSSiS    SSKS    S    SESSS    . 


tviaJd'S^oi^MCEP- 


■5 

1 

:  1 
:  i  ll 

IIS    11 

•""Nil  in 

o*!lir»*N Sj,    atiiasajj 

■Joap!iii,»!H 

„,,«.» 1^-  :  :  ,j    ^^  ,  ^gi^si:  s 

S"N"P"r 

i              8       

■I  ON  npu, 

^     :  .i=  :  ^     :^  j=   ■  ;^:  = :  :  jg 

1SWI-10V 

'■"""■'■■"•"v 

..    :  ;    .  :                  .  „  :  :  :  :  _ 

.»;it°i.;5i!T 

a  -                 '■'■     :.=:;:.::: 

=2:32=22l'rii'-'"»="s=   ^-H.-ti— =»   1 

.,PP  »„i'i».'.n 

"••2=!;:^  =  ^:-:-;-             ■---..,  =  =  -.= 

.,!,,  T"'.'',™;-, 

--Sa--'.-:,:;          --       .   -                      _-:,.,,;^«- 

.i.u.<...io»or 

gSS2gSSiis^4-.  =  ;^..S    i-i23SSS=2 

ISS'S'io 

2s:ssasass8ss2a332  ssssisisxt  1 

|.  p..,..o|       s          SS  ■  s       s  cs  s  sss 

-KfiBH  e^ssaagsssssgs^ssa  igsgissass 

■"!*•.» 

2S==RSSS!3aS  -ES(gS33    SSflSESSS  -R 

<.«v 

"r.-^:-  --'-,-    ^^r--se«     =.0-0==^»*t- 

.r.e 

l.SE-3                   :.          B^      =:i     !:aB:!====a 

.K.„„.0 

auouutQi£-,ii:-<su2^S«<a    saeEn'Ho.<xS-: 

-wqinnN 

MOVABLE     K I DNEY.  48  I 

1.  The  essential  cause  of  movable  kidney  lies  in  a  particular 
body-form. 

2.  The  chief  characteristics  of  this  body-form  are  a  marked 
contraction  of  the  lower  end  of  the  middle  zone  of  the  body 
with  a  diminution  in  the  capacity  of  this  portion  of  the  body 
cavity. 

3.  This  diminution  in  the  capacity  of  the  middle  zone  de- 
presses the  kidney  so  that  the  constricted  outlet  of  the  zone 
comes  above  the  centre  of  the  organ,  and  all  acts,  such  as 
coughing,  straining,  lifting,  flexions  of  the  body,  etc.,  which 
tend  to  adduct  the  lower  ribs,  press  on  the  upper  pole  of  the 
kidney  and  crowd  it  still  further  downward. 

4.  It  is  the  long-continued  repetition,  in  a  suitable  body-form, 
of  these  influences,  which  collectively  may  be  called  internal 
traumata,  that  gradually  produces  a  movable  kidney. 

5.  A  distinctly  movable  kidney  is  never  the  immediate  result 
of  a  single  injury  or  external  trauma. 


Am  Surg 


PNEUMOTOMY  FOR  ABSCESS  OF  THE  LUNG. 
With  Exhibition  of  Patient. 


By  W.  JOSEPH  HEARN,  M.D. 

AND 

W.  J.  ROE,  M.D., 

PHILADELPHIA. 


The  surgical  treatment  of  abscess  of  the  lung  by  pneu- 
motomy  is  not  a  modern  idea.  Many  cases  are  recorded  in 
literature  on  the  subject  of  intentional,  incidental,  or  accidental 
incisions  and  drainage  of  lung  abcesses,  with  varied  results. 
For  several  centuries  surgeons  have  recognized  the  necessity  of 
and  expressed  themselves  in  favor  of  such  a  procedure,  but  not 
until  the  latter  part  of  the  last  century  was  pneumotomy  generally 
practised.  Among  many  others,  such  men  as  M.  Reclus,  True, 
Paget,  Tuffier,  Keen,  A.  Pearce  Gould,  Le  Conte,  Terrier,  Carl 
Beck,  Sonnenberg,  Matas,  Parham,  and  Murphy  have  done  much, 
both  by  their  work  and  writings,  to  advance  this  department  of 
surgery. 

The  advent  of  the  Rontgen  rays  has  greatly  enhanced  its 
possibilities  by  assisting  to  definitely  locate  the  abscess.  The 
case  in  point  demonstrates  this  very  clearly,  as  the  first  two 
operations  were  performed  previously  to  the  employment  of  the 
rays.  Again,  the  employment  of  artificial  respiration,  by  means 
of  the  apparatus  devised  by  Fell  and  O'Dwyer,  or  that  of  Bloom, 
has  been  practically  demonstrated  by  Parham,  Keen  and  others, 
and  has  given  this  form  of  surgery  new  impetus  by  lessening 
the  dangers  of  an  incident  pneumothorax. 

Pneumotomy  has  a  wide  field  of  use,  but  is  especially  indi- 
cated in  the  following  conditions  :     {a)  In  abscesses,  such  as 


PNEUMOTOMY     FOK     ABSCESS    OF    THE    LUNG.  483 

a  single  abscess;  [d)  saccular bronchiectatic  abscess  ;  (c)  a  single 
tuberculous  abscess,  with  retention  of  secretion,  high  fever,  and 
localized  tuberculous  involvement  of  the  lung  tissue;  {d)  in 
localized  abscesses  from  the  entrance  of  foreign  bodies  into  the 
bronchi,  gunshot  and  penetrating  wounds  of  the  lung. 

The  time  being  limited  and  the  history  of  the  case  necessarily 
long,  we  have  endeavored  to  incorporate  only  the  practical  points 
of  direct  bearing. 

S.  L.  H.,male;  born  in  England  in  1875;  salesman  by  occupation. 
His  parents  are  in  good  health  ;  also  five  brothers  and  four  sisters,  and 
there  is  no  tubercular  history  in  his  ancestry.  His  grandparents  died 
of  senility. 

The  present  trouble  began  when  patient  was  between  three  and  four 
years  of  age.  Other  than  this  he  has  not  had  any  serious  illness.  He 
was  always  well  until  during  the  autumn  of  his. fourth  year,  when  his 
clothing  became  saturated  from  a  fall  into  a  river,  and  was  not  removed 
for  several  hours,  the  patient  remaining  out  in  the  cold  and  becoming 
thoroughly  chilled. 

Following  this,  he  was  very  ill  for  one  month  with  fever,  cough,  and 
pain  in  the  right  half  of  the  chest,  at  the  end  of  which  time  he  began 
to  cough  up  large  quantities  of  purulent  material,  and  about  the  end 
of  each  coughing  attack  the  material  would  be  quite  bloody,  and  some- 
times almost  pure  blood. 

He  improved  during  the  following  two  months,  at  the  end  of  which 
time  he  was  very  much  better,  but  continued  to  cough  up  considerable 
purulent  material,  and  subsequently  in  smaller  amounts,  and  there  was 
present  a  constant  offensive  exhalation. 

He  was  taken  to  Germany  for  treatment,  where  he  remained  for 
some  months,  and  was  treated  medicinally,  and  pronounced  incurable. 
He  was  also  treated  at  the  same  time  by  means  of  braces  for  genu  varum. 

One  year  after  the  onset  of  his  illness  his  parents  removed  with 
him  to  New  York,  having  been  first  advised  by  physicians  that  his 
condition  was  such  that  he  would  probably  not  survive  the  voyage. 
They  arrived  in  New  York  City  in  September,  1880,  and  two  weeks 
later  his  cough  become  more  troublesome,  accompanied  by  fever  and 
pain  in  the  right  side  of  the  chest,  but  his  appetite  remained  good. 
He  was  admitted  to  the  Jewish  Hospital,  where  he  remained  for  nine 
months. 


484  HEARN     AND     ROE, 

Diagnosis  unknown. 

After  residing  for  about  one  year  in  New  York  City  he  removed  to 
Richmond,  Va.,  where  he  resided  for  twelve  years,  and  during  that 
time  he  had  more  or  less  cough,  with  expectoration  of  considerable 
pus,  and  a  constant  offensive  odor  to  his  breath,  and  did  not  at  any 
time  feel  entirely  well. 

After  a  subsequent  very  brief  residence  in  Philadelphia  he  returned 
to  Richmond,  and  spent  seven  months  in  the  Retreat  for  the  Sick, 
without  receiving  any  benefit ;  but  was  told  by  Dr.  Levy  that  an  oper- 
ation was  required  to  effect  a  cure. 

He  again  removed  to  Philadelphia  in  December,  1895,  and  was 
soon  afterward  admitted  to  the  Jefferson  Hospital  during  the  service 
of  Dr.  W.  W.  Keen.     On  admission  the  following  notes  were  taken  : 

Temperature,  98^°;  pulse,  92 — full  and  soft ;  respiration,  24;  cough 
occurs  in  paroxysms,  and  with  it  the  expectoration  of  large  quantities 
of  purulent,  horribly  fetid  material ;  violent  coughing  has  been  fol- 
lowed by  blood-spitting;  complains  of  dyspnoea,  even  so  severe  as  to 
necessitate  sitting  posture ;  has  evening  chilliness  and  rather  profuse 
night-sweats;  complains  of  weakness,  and  has  lost  25  pounds;  pain 
varying  in  severity  through  right  lung ;  sputum  amounts  to  four  ounces 
twice  daily. 

On  December  19,  1895,  he  was  operated  on  by  Dr.  W.  W.  Keen, 
assisted  by  the  writers.  For  these  notes,  as  well  as  those  of  the  second 
operation,  we  are  indebted  to  the  courtesy  of  Dr.  Keen. 

A  curved  incision  downward  was  made  along  the  line  of  the  nipple, 
exposing  the  fifth  intercostal  space,  which  was  incised,  and,  believing 
the  pleura  to  be  adherent,  the  largest  needle  of  an  aspirator  was  intro- 
duced into  the  lung  to  a  depth  of  nine  centimetres,  along  which  a  pair 
of  forceps  were  introduced  and  separated  about  one  and  a  half  inches, 
and  were  drawn  out,  after  which  a  rubber  drainage-tube  was  inserted. 
Eight  days  later  Dr.  Keen  explored  further,  breaking  through  the  wall 
of  the  sinus,  which  had  formed,  with  a  curved  haemostatic  forceps  in 
three  different  directions — upward  and  inward,  and  again  on  the  fol- 
lowing day  in  two  directions. 

Twelve  days  after  the  operation  the  patient  was  etherized,  and  Dr. 
Keen  explored  carefully  with  his  finger  in  different  directions,  and 
finding  considerable  resistance  at  one  point  he  explored  with  a  curved 
sound,  and  introduced  a  No.  30  catheter  and  fastened  it  in  place  with 
a  stitch.  These  explorations  were  unsuccessful  in  finding  the  abscess 
or  its  tract. 


PNEUMOTOMY    FOR     ABSCESS    OF    THE    LUNG.  485 

He  was  readmitted  to  the  Jefferson  Hospital  in  November,  1896, 
during  the  service  of  Dr.  W.  W.  Keen,  and  the  following  notes  of 
physical  examination  were  made  : 

AuscuUation  of  Right  Half  of  Chest.  Absence  of  vesicular  murmur 
below  the  line  of  the  spinous  process  of  the  eighth  dorsal  vertebra  and 
the  cartilage  of  the  seventh  rib  in  front,  with  frequent  loud  gurgling 
heard  below  this  line,  and  especially  posterior.  Above  this  line  the 
•vesicular  murmur  is  impaired  and  harsh,  with  crepitant  and  subcrepi- 
tant  rales;  but  the  murmur  soon  becomes  normal  toward  apex  of  chest. 
Vocal  resonance  is  much  decreased  below  and  increased  just  above  the 
line  for  a  very  limited  area.  Above  this  it  is  normal.  Left  lung  is 
normal. 

Percussion  of  Right  Half  of  Chest.  Gives  good  resonance  until 
approaching  the  line,  when  the  sound  is  rapidly  changed  and  becomes 
dull,  and  a  little  below  becomes  flat,  which  flatness  is  continuous  with 
that  of  the  liver.  There  is  more  tenderness  on  right  side.  Vocal 
fremitus  is  lost  below  the  line,  but  about  the  ssime  above  as  upon  the 
opposite  side  of  the  chest.  The  daily  quantity  of  pus  coughed  up 
amounted  to  about  one  pint,  which  was  examined  by  Dr.  Harris,  who 
found,  beside  the  ordinary  composition  of  pus,  the  bacillus  fetidus, 
but  no  tubercle  bacilli,  lung  tissue,  or  elastic  fibre.  Urine  examination 
negative. 

Second  operation  on  November  2.9,  1896,  by  Dr.  W.  W.  Keen, 
assisted  by  the  writers. . 

An  aspirating  needle  was  introduced  posteriorly  in  the  eighth  inter- 
space, and  apparently  some  pus  escaped.  With  the  needle  in  position 
two  inches  of  the  eighth  and  ninth  ribs  were  resected.  The  pleural 
surfaces  were  found  adherent,  and  were  incised,  and  the  lung  tissue 
was  penetrated  with  the  finger  to  a  depth  of  three  inches,  following 
the  direction  of  the  needle;  then  in  a  downward  direction  to  opposite 
the  eleventh  interspace,  and  also  in  an  upward  direction  to  a  corre- 
sponding extent ;  then  with  the  finger  the  pleural  surfaces  were  sepa- 
rated in  a  downward  direction  to  the  level  of  the  diaphragm,  after 
which  a  large  rubber  drainage-tube  was  inserted. 

Decetnber  7,  1896.  Dr.  Keen  introduced  through  the  drainage- 
tube  a  sound  in  three  directions  into  the  upper  portion  of  lung  to  a 
distance  of  six  and  a  half  inches  without  finding  any  cavity. 

\oth.  Drainage-tube  removed  and  was  found  to  be  five  and  a  half 
inches  into  lung,  including  chest  wall.  These  explorations  were  also 
unsuccessful  in  finding  the  abscess  or  its  tract. 


486  HEARN    AND     ROE, 

Patient  was  readmitted  to  the  hospital  on  December  19,  1898,  dur- 
ing the  service  of  Dr.  W.  Joseph  Hearn.  Since  he  left  the  hospital  in 
December,  1896,  his  condition  had  practically  remained  unchanged. 
He  has  had  daily  from  six  to  eight  paroxysms  of  coughing,  with  expec- 
toration of  exceedingly  offensive  pus,  but  no  blood. 

A  specimen  of  the  sputum  and  pus  coughed  up  was  examined  by  Dr. 
J.  D.  Robinson,  pathological  resident,  as  follows: 

Specimen  stained  by  ordinary  method,  also  for  tubercle  bacilli. 
Histological  examination  shows  numerous  pus  and  a  few  epithelial  cells 
and  granular  debris.  Bacteriological  examination  shows  numerous 
bacilli,  a  few  micrococci,  and  a  few  streptococci.  Tubercle  bacilli 
not  found.     Urine  examination  negative. 

His  deplorable  condition  was  such  that  we  had  to  isolate  him.  By 
allowing  the  pus  to  accumulate  in  the  cavity  until  filled  we  were 
able  to  demonstrate  with  the  fluoroscope  that  it  was  in  or  about  the 
base  of  the  lung.  A  skiagraph  was  also  taken  with  the  abscesses  only 
partially  filled,  as  the  patient  could  not  retain  the  pus  in  a  recumbent 
position. 

Having  assisted  Dr.  Keen  in  his  most  careful  and  thorough  explora- 
tions of  almost  the  entire  lung,  we  decided  that  if  the  abscess  was  in 
the  lung,  it  was  in  or  about  the  central  portion  of  the  base,  or  else  was 
a  case  of  encysted  empyema  between  the  base  of  the  lung  and  the  dia- 
phragm, or  the  inner  surface  and  the  pericardium,  or  possibly  a  sub- 
diaphragmatic abscess  with  pulmonary  sinus. 

Against  the  diagnosis  of  encysted  empyema  was  the  presence  of  the 
offensive  odor,  in  contrast  to  the  case  reported  by  D.  S.  Fairchiid,  in 
which  there  was  no  odor  to  the  pus.  Loud  gurgling  rales  could  be 
heard,  and  the  patient  felt  a  decided  pressure,  which  frequently  caused 
him  to  vomit  soon  after  eating.  This  pressure  was  in  the  region  of 
the  base  of  the  lung  and  diaphragm  when  the  abscess  became  filled. 

Ether  was  administered.  A  curved  incision  was  made  over  the  sixth 
rib  in  the  mammiliary  line,  and  two  inches  of  the  osseous  extremity  of 
the  rib  resected.  The  parietal  pleura  was  opened  and  the  visceral 
pleura  was  found  adherent,  but  could  easily  be  separated.  With 
the  fingers  the  pleural  surfaces  were  separated  between  the  base 
of  the  lung  and  the  diaphragm  and  between  the  lung  and  the 
pericardium  as  far  as  the  fingers  would  reach,  both  backward  and 
upward ;  but  no  evidence  of  pus  was  found  and  no  dense  adhe- 
sions. At  the  same  time  the  lung  was  carefully  palpated  (Tuffier's 
method  of  locating  an    abscess,  and  preferred   by  Sonnenberg),  but 


PNEUMOTOMY    FOR    ABSCESS    OF    THE     LUNG.  487 

nothing  specially  abnormal  was  indicated.  While  exploring  backward 
between  the  base  of  the  lung  and  the  diaphragm  a  decided  resistance 
was  encountered.  Instead  of  the  fingers  passing  backward  and  down- 
ward over  the  dome  of  the  diaphragm  they  met  with  this  resistance, 
which  carried  them  upward  and  backward  against  the  lung,  showing 
the  pleural  surfaces  to  be  firmly  adherent. 

By  catching  the  visceral  surface  at  this  point  between  the  fingers  it 
was  found  to  be  elastic,  and  could  be  drawn  sufficiently  forward  to  be 
readily  observed  in  the  wound,  and  also  gave  the  sensation  of  being 
part  of  a  wall  of  an  empty  cavity.  Believing  that  this  was  the  abscess 
wall,  we  decided  to  make  a  posterior  incision,  which  would  enable  us 
to  employ  direct  drainage.  We  therefore  made  a  curved  incision  just 
beneath  the  angle  of  the  scapula,  and  exposing  the  ninth  rib,  resected 
two  inches  of  it.' 

The  pleural  surfaces  were  evidently  adherent,  thickened,  of  a  gray 
appearance,  and  gave  the  sensation  of  composing  the  abscess  wall,  and 
following  the  rule  laid  down  by  Sonnenberg :  f'lf  the  pulmonary  tis- 
sues are  hard,  divide  them  with  a  knife,  as  there  is  no  danger  of  hem- 
orrhage ;  if  the  pulmonary  tissues  are  soft,  divide  them  with  the  cautery, 
as  there  is  great  danger  of  hemorrhage."  On  incising  this  in  the 
direction  of  the  ribs  we  opened  directly  into  the  abscess  cavity,  and 
several  drachms  of  pus  escaped.  The  walls  of  the  abscess  cavity  were 
everywhere  soft  and  elastic,  and  felt  smooth  on  the  interior,  and,  with 
two  fingers  in  the  abscess  cavity,  they  could  be  carried  their  full 
length  in  every  direction  without  meeting  with  any  special  resistance. 

At  the  upper  and  inner  portion  of  the  cavity  could  be  felt  two  open- 
ings, apparently  of  bronchi.  A  long  probe  was  then  passed  into  one 
of  these  openings,  and  was  readily  carried  up  through  the  bronchus 
into  the  trachea,  which  was  repeated  several  times,  and  at  each  pro- 
duced a  severe  paroxysm  of  coughing,  the  patient  not  being  entirely 
anaesthetized.  As  the  patient  coughed,  mucus,  pus,  and  blood  were 
expelled  through  the  wound. 

Two  large  rubber  drainage-tubes  were  introduced  into  the  abscess, 
and  the  cavity  was  distended  by  iodoform  gauze  packing,  A  small 
rubber  drainage-tube  was  put  in  the  anterior  wound. 

We  quote  subsequent  notes  by  Dr.  A.  N.  Mahon,  resident  physician  : 

"December  21,  1898.   Patient  reacted  well  from  ether ;  wound  dressed. 


*  It  is  interesting  to  note  that  Carl  Beck  says  that  old  cavities  can  be  best  reached  hy 
an  incision  at  the  angle  of  the  scapula. 


488  HEARN     AND     ROE, 

looking  well ;  no  pus  from  anterior  tube  ;  a  considerable  amount  from 
posterior  tubes ;  there  has  been  no  expectoration  of  pus. 

"  22d.     Pus  is  coming  freely  from  both  anterior  and  posterior  tubes. 

"  2<^th.  Part  of  stitches  removed  ;  pus  still  coming  freely  from  both 
wounds;  tubes  shortened  on  25th  and  27th.  There  has  been  no  ex- 
pectoration of  pus  except  on  the  23d,  when  it  was  very  slight — about 
one  drachm  ;  patient  sitting  up. 

"  3IJ'/.     Balance  of  stitches  removed  ;  patient  walking  around. 

"/anuaryi,  1899.  Discharged  in  good  condition;  drainage-tubes 
still  in  place,  having  been  shortened ;  pus  draining  freely ;  wounds 
looking  well ;  no  expectoration." 

The  suppuration  in  the  anterior  wound  was  clearly  due  to  secondary 
infection,  and  soon  ceased,  the  wound  healing  completely  in  sixteen 
days.  The  pyothorax  in  this  case  did  not  delay  convalescence.  One 
of  the  posterior  tubes  was  dispensed  with  in  three  weeks. 

The  abscess  cavity  was  irrigated  daily  in  the  Out-patient  Depart- 
ment for  the  following  year  and  a  half,  after  which  the  patient  went 
South,  and  kept  up  the  irrigation  himself. 

During  this  time  the  local  effect  upon  the  abscess  wall  of  many 
fluids  by  irrigation  was  noted,  the  principal  of  which  are  the  following: 
Plain  sterile  water  ;  normal  salt  solution ;  boric  acid  saturated  solu- 
tion ;  hydrogen  dioxide  in  5  to  15-volume  solutions;  listerine  diluted; 
carbolic  acid,  i  to  3  per  cent,  solution  ;  potassium  permanganate,  i 
to  30,000  to  I  to  1000  ;  pyoktanin,  i  to  30,000  to  i  to  1000;  forma- 
lin, half  of  I  per  cent. ;  distillate  of  moss,  prepared  by  John  John- 
son ;  palladium  bichloride,  i  to  5500. 

The  most  appreciable  benefit  derived  from  irrigation  by  any  or  all 
was  the  cleansing.  None  had  any  influence  in  lessening  the  size  of 
the  cavity,  but  some  were  instrumental  in  considerably  lessening  the 
quantity  of  pus  formed. 

The  bichloride  of  palladium  solution  evidently  did  more  to  lessen 
the  quantity  of  pus  than  any  other,  and  also  prevented  or  relieved 
dermatitis  or  excoriation  of  the  skin  surfaces,  which  frequently  occurred 
from  the  irritation  caused  by  purulent  discharge  while  using  other  irri- 
gants.  Further,  it  did  not  cause  any  unpleasant  eff"ects,  even  if  allowed 
to  be  coughed  up  daily. 

The  permanganate,  pyoktanin,  and  formalin  solutions  usually  excited 
a  dry  cough,  and  they  could  only  be  used  for  a  few  days  in  succession. 
The  colored  fluids  were  used  also  as  a  diagnostic  means ;  with  the 
patient  lying  upon  his  left  side  the  abscess  cavity  could  be  filled,  and 


PNEUMOTOMY     FOR    ABSCESS    OF    THE    LUNG.  489 

then,  by  holding  a  compress  over  the  drainage-tube,  the  patient  would 
cough  up,  and  all  of  the  pus  and  mucus  would  be  equally  stained  by 
the  solution.  This  to  a  certain  extent  demonstrated  that  there  was 
no  other  large  pus  cavity  in  the  chest,  for  if  such  were  the  case  the 
contained  pus  could  scarcely  become  so  thoroughly  stained  by  being 
mixed  with  the  pus  from  the  injected  cavity,  or  by  coming  in  contact 
with  the  stained  walls  of  the  respiratory  tract  while  being  expelled. 

During  these  two  years  he  was  never  compelled  to  expel  the  con- 
tents of  the  abscess  cavity  through  the  respiratory  tract,  except  when 
the  drainage-tube  (although  quite  large)  became  occluded  by  thick 
mucus  or  the  dressing  became  saturated. 

His  general  health  was  vastly  improved.  Gained  in  weight  and 
strength,  and  seldom  felt  bad.  Previous  to  draining  the  cavity  he 
had  occasional  severe  chills,  followed  by  fever,  but  during  this  time 
he  was  free  from  such.  The  horribly  offensive  odor  was  very  greatly 
lessened,  and  life  was  much  more  pleasant,  except  for  the  annoy- 
ance of  the  daily  irrigation  and  the  necessity  for  frequent  change  of 
dressings.  For  these  reasons  he  made  an  earnest  appeal  for  further 
relief. 

We  decided  to  made  another  attempt  to  relieve  his  condition,  hoping 
that  we  could  completely  excise  the  abscess  cavity,  or,  if  we  found 
this  not  expedient,  we  could  excise  a  portion  of  the  cavity  and  suture 
the  remainder  to  the  surface  of  the  skin,  converting  it  into  an  open 
cavity — a  plan  suggested  by  Dr.  J.  Chalmers  Da  Costa. 

He  was  readmitted  to  the  hospital  on  December  14,  1900,  and  we 
operated  on  the  i8th.  Again,  as  in  all  the  previous  operations,  ether 
was  administered.  A  tri-flap  or  Y-incision  was  made  down  to  but  not 
into  the  sinus,  exposing  a  portion  of  the  eighth  and  ninth  ribs,  which, 
having  been  re-formed,  were  again  resected  three  and  four  inches 
respectively.  The  middle  of  the  resected  portion  of  the  ninth  rib 
contained  a  large  fenestra,  occupied  by  the  sinus.  The  sinus  and  a 
portion  of  the  abscess  wall  were  dissected  free  from  the  surrounding 
pleura  and  lung  tissue  to  a  depth  of  about  one  and  a  half  inches. 

Some  bleeding  was  taking  place  from  the  lung  tissue,  and  on  account 
of  the  extent  of  the  abscess  cavity,  we  decided  to  excise  by  circular 
incision  the  portion  of  wall  which  we  had  dissected  free,  after  which 
we  sutured  the  circular  margin  of  the  abscess  cavity  to  the  margin 
of  the  skin  flap.  Our  triangular  flap,  which  we  had  designed  for 
this  purpose,  worked  admirably,  allowing  a  continuous  and  regular 
approximation. 


490  HEARN     AND     ROE, 

The  cavity  was  packed  with  iodoform  gauze,  and  the  patient,  as  in 
all  the  previous  operations,  convalesced  rapidly,  and  was  up  and 
around  in  ten  days.  One  month  after  operation  we  took  the  follow- 
ing measurements  of  the  cavity  and  had  this  delineation  made  : 

The  cavity  extends  obliquely  upward,  inward,  and  forward.  There 
is  no  longer  any  retention  of  secretion  within  the  cavity,  the  capacity 
of  which  constantly  alternates  with  respiration.  On  deep  or  forced 
expiration  the  walls  of  the  cavity  approximate.  At  the  apex  of  the 
cavity,  where  the  bronchi  enter,  a  polypus  extends  into  the  cavity  about 
2  cm.  and  8^  cm.  from  the  surface.  There  is  a  narrow  septum  divid- 
ing the  apical  portion  ^}4  cm.  from  the  surface.  The  depth  of  the 
upper  surface  of  the  cavity  is  7  cm.  and  lower  95^  cm.  Its  diameter 
in  vertical  is  5  cm.  and  lateral  3  cm.  The  walls  of  this  cavity  are 
quite  elastic  and  will  admit  of  very  considerable  distention,  and  this 
readily  accounts  for  the  large  quantities  of  pus  (four  to  six  ounces) 
expelled  at  frequent  intervals  previous  to  drainage. 

A  specimen  of  the  excised  wall  of  the  cavity  was  examined  in  the 
laboratory  of  the  Jefferson  Medical  College  Hospital  by  Dr.  John 
Funk. 

Upon  microscopical  examination  the  inner  surface  of  the  wall  of 
the  cavity  is  lined  with  translucent  material,  which  did  not  stain  by 
Weigert's  method,  nor  did  it  take  any  other  basic  or  acid  stain.  The 
remainder  of  the  wall  was  apparently  composed  of  numerous  laminae 
of  a  dense  homogeneous  substance.  The  sections  stain  with  h^ema- 
toxylin  and  eosin;  toluidin  blue  and  eosin  retain  the  basic  stain.  Sec- 
tion stained  by  Weigert's  fibrin  stain  retains  the  stain  throughout  the 
section,  with  the  exception  of  the  translucent  substance  referred  to 
above.  The  translucent  material  is  undoubtedly  degenerated  debris, 
and  the  wall  of  the  cavity  is  composed  of  laminae  of  fibrin. 

He  was  benefited  by  the  last  operation  as  follows :  The  offensive 
odor  is  practically  entirely  gone  ;  he  is  relieved  of  the  necessity  of 
having  the  cavity  irrigated  and  the  annoyance  of  wearing  a  drainage- 
tube.  He  complains,  however,  of  the  annoyance  of  wearing  and  fre- 
quently changing  the  dressings,  and  that  each  day  he  is  compelled  to 
cough  up  small  quantities  of  mucopurulent  material,  which  evidently 
comes  from  other  portions  of  the  bronchial  tract,  and,  although  he  is 
vastly  improved  in  many  respects,  and  his  general  health  (which  pre- 
viously was  very  poor)  is  now  good,  and  the  horribly  offensive  odor, 
which  practically  compelled  him  to  live  a  recluse,  is  gone,  he  is  not 
cured. 


P  N  E  U  M  O  T  O  M  Y     FOR     ABSCESS     OF     THE     LUNG.  49  I 

He  desires  to  have  the  abscess  obliterated  and  the  opening  in  the 
chest  closed,  and  also,  if  possible,  to  be  relieved  of  the  present  muco- 
purulent expectoration. 

The  following  questions  arise  :  What  were  the  etiological 
factors  in  this  case?  i.  Is  this  an  abscess  of  the  lung  follow- 
ing gangrene?  2.  Is  this  a  saccular  bronchiectatic  cavity? 
3.  What  is  his  present  condition,  and  what  can  be  done  to 
relieve  or  cure  it  ? 

The  exposure  to  cold,  followed  by  an  acute  illness  (probably 
pneumonia),  and  immediate  subsequent  expectoration  of  large 
quantities  of  pus  and  blood,  with  a  history  of  continuous  ill 
health,  associated  with  expulsion  of  quantities  of  purulent  mate- 
rial and  the  finding  of  one  large  cavity,  lead  us  to  believe  that 
this  was  an  abscess  following  localized  gangrene  of  the  lung 
in  contradistinction  to  saccular  bronchiectatic  cavities,  which 
would  develop  gradually  and  probably  never  attain  such  size. 

Had  the  sputum  been  examined  early  in  the  case  elastic  fibre 
and  lung  tissue  would  probably  have  been  found.  The  long 
duration  of  the  cavity  had  rendered  it  smooth  on  its  interior 
and  formed  a  thick  fibro-elastic  wall,  with  little  or  no  surround- 
ing induration. 

Although  we  believe  that  there  is  only  this  one  abscess 
cavity,  yet  his  present  condition  strongly  suggests  secondary 
bronchiectasis.  How  much  this  condition  is  the  result  of  the 
cough  or  of  the  associated  cirrhosis  of  the  lung,  which  evi- 
dently is  present,  especially  in  the  lower  lobe,  we  can  only 
surmise. 

As  to  his  further  treatment :  at  the  time  of  last  operation  we 
decided  to  subsequently  obliterate  the  cavity  by  promoting 
adhesions  through  the  use  of  the  cautery,  but  later  evidence  of 
the  probable  existence  of  some  degree  of  bronchiectasis  altered 
our  decision.- 

If  we  obliterate  this  cavity  by  causing  adhesion  between  the 
surfaces  we  would  only  increase  the  bronchiectatic  condition  by 
increasing  the  traction  of  the  cirrhotic  lung  tissue.  Therefore, 
we  believe  that  to  cure  this  condition  it  is  necessary  to  remove 
the  greater  portion   of  the   lower  ribs,  with   their   periosteum, 


492  HEARN     AND     ROE, 

allowing  the  chest  wall  to  fall  in,  and  by  this  means  obliterate 
not  only  the  original  cavity,  but  the  bronchiectatic  cavities  as 
well. 

This  plan  was  suggested  by  Dr.  Oscar  H.  AUis  in  1891  for 
the  cure  of  tuberculous  cavities ;  but  so  far  as  we  know  it  h£^s 
never  been  suggested  for  bronchiectasis,  and  if  the  members  of 
this  Association  have  no  better  suggestion  to  make,  we  will 
resort  to  this  procedure. 

In  reviewing  the  case  there  are  certain  facts  evident :  The 
localization  of  a  cavity  in  the  lungs,  which  collapses  when 
empty,  having  soft,  tough,  elastic  walls,  is  most  difficult.  Few 
patients  can  stand  this  operation  without  a  general  anaesthetic, 
and,  when  given,  the  contents  of  the  abscess  will  certainly  be 
expelled;  and,  even  though  an  abscess  wall  of  this  character 
should  be  reached  by  an  aspirating  needle,  it  would  be  carried 
in  front  of  the  needle  and  rarely  penetrated.  If  the  operation 
could  be  performed  under  local  anaesthesia  this  difficulty  would 
be  largely  overcome,  as  the  abscess  wall  would  offer  greater 
resistance,  and  if  palpation  were  employed  the  resistance  would 
again  be  encountered. 

In  this  case  there  was  no  difficulty  experienced  from  the 
administration  of  ether,  notwithstanding  the  warning  of  Carl 
Beck  to  the  contrary,  that  ether  should  never  be  given,  and  for 
a  general  anaesthetic  chloroform  only  should  be  used. 

Again,  the  cavity  was  freely  irrigated  from  the  day  of  oper- 
ation, and  no  difficulty  was  encountered,  even  though  the 
bronchus  became  flooded  and  the  patient  was  compelled  to 
cough.  Another  point  demonstrated  in  his  case  is  that,  even 
though  two  large  drainage-tubes  were  inserted,  when  the 
abscess  cavity  was  first  opened,  and  although  the  cavity  freely 
communicated  with  the  bronchus,  there  M^as  neither  then  nor 
subsequently  any  impairment  of  respiration.  On  the  contrary, 
Sonnenberg  advises  tamponing  the  abscess  cavity  of  the  lung, 
which  communicates  with  the  bronchus,  in  order  to  prevent 
embarrassment  of  respiration.  When,  however,  the  patient 
was  compelled  to  cough,  he  experienced  difficulty  unless  a 
compress  was  held  over  the  wound  and  tube. 


PNEUMOTOMY    FOR    ABSCESS    OF    THE    LUNG.  493 

BlISLIOGRAPHY. 

AUis,  Oscar  H.     Transactions  of  the  Pennsylvania  State  Medical  Society,  1891. 

Beck,  Carl.     Journal  of  the  American  Medical  Association,  October  2,  1897. 

Fairchild,  D.  S.     Ibid.,  September  30,  1898. 

Gould,  A.  Pearce.     Practitioner,  February,  1900. 

Keen,  W.  W.    Proceedings  of  the  American  Surgical  Association,  1901. 

Le  Conte.     Philadelphia  Medical  Journal,  April  14,  1900. 

Matas.     Annals  of  Surgery,  April,  1899. 

Murphy.  Journal  of  the  American  Medical  Association,  July  23,  30,  and  August  6, 
1898. 

Paget.     Surgery  of  the  Chest,  1896. 

Parham.  Monograph,  1899:  Thoracic  Resection  for  Tumors  Growing  from  the 
Bony  Wall  of  the  Chest. 

Reclus.     Paget :  Surgery  of  the  Chest,  Appendix  A. 

Sonnenberg.     Wiener  medicinische  Blatter,  1897,  No.  40. 

Terrier.     Annales  de  la  Societe  Beige  de  Chirurgie,  June,  1900. 

True.     Chirurgie  du  Poumon,  1885. 

Tuffier.     Medicine,  December,  1897. 


EXCISION  OF  A  PART  OF  THREE  RIBS  AND  A 

PORTION   OF   THE   DIAPHRAGM 

FOR   SARCOMA. 


By  C.  B.  porter,  M.D., 

BOSTON,  MASS. 


This  case  is  reported  as  a  contribution  to  the  surgery  of  the 
chest. 

The  patient,  H.  J.  D.,  male,  aged  forty-one  years,  born  in  Boston, 
entered  the  Massachusetts  General  Hospital  on  January  i6,  1900. 
Occupation,  pressman. 

The  previous  and  family  history  is  of  no  importance. 

The  present  illness  began  about  three  and  one-half  months  ago. 
At  that  time  he  felt  a  stitch-like  pain  in  the  right  side,  localized  in  the 
anterior  axillary  line  at  the  level  of  the  eighth  rib.  The  pain  was 
increased  on  deep  inspiration  and  became  especially  severe  when 
physical  activity  caused  increased  respiratory  movements. 

Three  weeks  later  the  patient  first  noticed  a  swelling  at  the  seat  of 
the  pain.  The  tumor  was  hard  at  first,  but  became  softer  as  it 
increased  in  size.  At  no  time  has  the  growth  been  tender  to  ordi- 
nary pressure. 

Coincident  with  the  growth  the  patient  has  been  losing  strength 
and  weight.  During  the  past  three  months  he  has  lost  eighteen 
pounds. 

Physical  Examination.  Well-developed  and  nourished  man  :  heart 
and  lungs  negative. 

On  the  right  thoracic  wall  is  a  dome-shaped  tumor,  the  size  of  one- 
half  a  medium-sized  cocoanut.  The  centre  of  the  tumor  is  at  the 
level  of  the  eighth  rib  in  the  anterior  axillary  line.  The  tumor  moves 
with  respiration.     (Figs.  1  and  2.) 

The  growth  is  not  adherent  to  the  skin,  but  is  firmly  attached  to  the 


EXCISION   OF    RIBS    AND    OlAPHKAGM    FOR    SARCOMA.       495 

ribs.  It  is  soft  on  palpation,  suggesting  semi-fluid  contents.  On  deep 
pressure  the  tumor  is  tender.  The  chest  was  examined  by  Dr.  F.  C. 
Shattuck,  who  found  no  abnormal  respiratory  sounds. 

In  order  to  determine  if  the  process  was  of  tubercular  origin,  the 
patient  was  subjected  to  the  tuberculin  test,  with  a  negative  result; 
TTLxv  of  a  I  per  cent,  solution  of  tuberculin  was  injected  deep  into 
the  thigh.     X-ray  of  the  chest  was  negative. 

Blood  Examination.  Reds,  5,836,000;  whites,  14,000;  haemo- 
globin, 65  per  cent.  ;  urine,  negative. 

Operation.  A  preliminary  tracheotomy  was  done,  with  the  patient 
in  the  sitting  position.  The  object  of  doing  a  tracheotomy  was  to  be 
ready  to  inflate  the  lung  by  means  of  a  rubber  tube  passed  through 
the  tracheal  opening,  if  necessary.  Other  operators  have  found  this 
expedient  necessary  where  sudden  shock  was  induced  by  collapse  of 
the  lung. 

The  patient  was  then  placed  upon  the  operating-table,  with  the  right 
side  elevated  and  the  right  arm  extended  over  the  head. 

A  curved  incision  through  the  skin  was  then  made,  starting  in  the 
mid-axillary  line  at  the  fourth  rib;  it  was  then  continued  downward 
to  the  infracostal  edge  of  the  ribs,  thence  forward  to  the  edge  of  the 
rectus. 

A  flap  thus  outlined  was  turned  up  from  below.  On  dissecting 
away  the  subcutaneous  fat  the  growth  was  found  to  be  encapsulated. 
The  capsule  being  quickly  exposed,  appeared  greenish-black,  rough 
and  elastic  to  pressure.  On  opening  the  capsule  there  was  a  gush  of 
blood,  which  continued,  except  when  pressure  with  gauze  was  used. 
(Figs.  3  and  4.) 

Although  many  clamps  were  put  on,  the  hemorrhage  was  still  rapid. 
It  was  evident  that  the  tumor  could  not  be  dissected  from  the  ribs  on 
account  of  this  uncontrollable  hemorrhage.  By  means  of  a  large  spoon 
curette  the  entire  mass  was  rapidly  scraped  away  down  to  the  ribs. 
The  bleeding  was  now  partially  controlled  by  many  clamps  and 
pressure  with  gauze. 

The  reason  for  this  type  of  hemorrhage  will  be  seen  on  examination 
of  the  pathological  report.  The  growth  we  had  to  deal  with  was  the 
telangiectatic  type  of  a  myelogenous  sarcoma.  In  this  form  of  growth 
the  blood-supply  is  carried  on  by  sinuses  irregularly  arranged.  It  was 
the  bleeding  from  these  sinuses,  which  could  not  be  clamped,  that  gave 
rise  to  this  difficulty. 

On  examining  the  exposed  surface  of  the  ribs  the  growth  was  found 


496  PORTER, 

to  have  involved  the  seventh,  eighth,  and  ninth  ribs,  which  was  con- 
firmed by  frozen  sections. 

These  ribs  were  then  divided  in  the  mid  axillary  line,  clearing  the 
margin  of  the  growth  by  three-fourths  of  an  inch.  On  elevating  the 
ends  of  the  divided  ribs,  the  lung  could  be  seen  in  a  partly  collapsed 
condition. 

The  condition  of  sudden  shock  due  to  collapse  of  the  lung,  which 
had  been  anticipated  on  account  of  the  experiences  of  other  operators, 
did  not  occur.  Dr.  M.  H.  Richardson,  who  watched  the  pulse  at 
this  stage  of  the  operation,  noticed  no  immediate  change  in  the  rate 
or  quality.  There  was  no  cyanosis  or  respiratory  distress ;  the  rate 
and  depth  of  respiration,  however,  increased. 

The  intercostal  muscle  between  the  sixth  and  seventh  ribs  was  next 
divided  with  the  costo-chondral  ligaments  and  cartilage.  On  elevat- 
ing the  upper  portion  of  the  ribs  thus  divided  the  growth  from  the 
ribs  was  found  to  have  extended  into  the  pleural  cavity.  The  intra- 
thoracic portion  of  the  growth  was  cylindrical,  covered  by  a  reflection 
of  the  parietal  pleura,  with  its  long  diameter  pointing  downward  and 
inward. 

The  intercostal  muscle,  costo-chondral  ligament,  and  cartilage  of 
the  ninth  and  tenth  ribs  were  next  divided.  It  was  now  found  that 
the  lower  pole  of  the  intrathoracic  portion  of  the  tumor  was  adherent 
to  the  diaphragm.  An  effort  was  made  to  dissect  the  growth  away. 
This,  however,  could  not  be  done  without  leaving  a  portion  of  the 
sarcoma  on  the  diaphragm. 

The  diaphragm  was  then  cut  away  from  the  growth  by  an  elliptical 
incision,  removing  half  an  inch  of  normal  diaphragm  outside  the 
margin  of  the  malignant  growth.  With  this  the  ribs,  tumor,  and 
diaphragm  were  removed. 

On  opening  the  diaphragm  the  intestines  came  through  into  the 
pleural  cavity.  They  were  replaced  and  held  back  by  gauze.  The 
opening  in  the  diaphragm  was  then  closed  by  a  "  shoemaker's 
stitch"  of  animal  tendon.  After  tying  the  intercostal  arteries  and 
several  other  vessels  the  skin  flap  was  turned  down  and  closed  with 
interrupted  silkworm-gut  sutures.  At  the  upper  end  of  the  incision 
an  opening  was  left,  and  through  this  a  rubber  tissue  gauze  wick  was 
put  into  the  pleural  cavity. 

At  the  close  of  the  operation  the  patient  was  sufTering  considerably 
from  shock.  The  shock  came  on  gradually,  and  was  evidently  due 
to  the  loss  of  blood  and  not  from  the  condition  of  the  lung.     He  was 


} 


'T^     60 


EXCISION    OF    RIBS    AND    DIAPHRAGM    FOR    SARCOMA.       497 

infused  with  1000  c.c.  of  normal  salt  solution  and  stimulated.      The 
pulse  was  160. 

On  recovering  consciousness  the  patient  suffered  from  dyspnoea, 
which  was  much  relieved  by  the  administration  of  oxygen.  The 
oxygen  was  used  during  the  first  week. 

The  respiration  was  wholly  thoracic.  On  the  following  morning  the 
patient  had  reacted  from  the  shock. 

On  the  second  day  respiration  could  be  heard  at  the  level  of  the 
fifth  rib,  and  on  the  third  day  at  the  sixth  rib  in  the  mid-axillary 
line. 

On  the  fourteenth  day  the  chest  was  examined  by  Dr.  R.  C.  Cabot, 
who  found  that  the  right  lung  had  reached  its  full  expansion,  and  that 
the  respiratory  sounds  were  normal.  The  wick  and  stitches  were 
removed  on  the  tenth  day,  and  on  the  eighteenth  day  the  patient  was 
allowed  to  be  up. 

The  patient  was  up  and  about  on  the  twenty-first  day  as  usual,  when 
he  had  a  severe  chill,  followed  by  a  temperatureof  104.5°.  Nothing 
abnormal  was  found  in  the  chest  at  this  time.  Four  days  later  fluid 
was  found  in  the  right  thoracic  cavity  at  the  level  of  the  fourth  rib,  in 
the  mid-axillary  line.  Drainage  was  not  employed,  in  hopes  that  the 
exudate  might  absorb. 

Ten  days  later  fluid  was  still  present,  and  the  upper  end  of  the  in- 
cision was  reopened.  Several  ounces  of  a  brownish  straw-colored  fluid, 
the  consistency  of  consomme,  came  out.  Cultures  from  this  fluid 
showed  numerous  colonies  presenting  a  variety  of  diplococci ;  no 
streptococci  were  present.  Drainage  was  continued  for  two  weeks. 
From  now  on  the  convalescence  was  rapid.  The  sinus  closed  at  the 
end  of  two  months. 

Sixteen  months  after  the  operation  the  patient  was  seen.  He  has 
gained  thirty-eight  pounds,  and  there  is  no  evidences  of  recurrence  of 
the  sarcoma.  There  is  a  marked  bulging  between  the  ribs,  bordering 
the  resected  area.  This  condition  has  been  increased  by  the  patient's 
occupation,  which  requires  him  to  work  in  the  stooping  position. 

Pathologisfs  Repoj-t.  The  specimen  consisted  of  three  ribs,  two  of 
which  were  more  or  less  intact,  the  longest  measuring  13  cms.  From 
the  middle  rib  there  started  a  growth  of  a  somewhat  hour-glass  shape, 
consisting  of  a  continuous  extrapleural  and  intrapleural  growth.  The 
opening  through  which  the  tumor  mass  passed  measured  9  cms.  in 
diameter.  The  surface  was  more  or  less  smooth,  somewhat  lobulated. 
The  two  parts  of  the  growth  each  measured  12.5  by  8  cms. 

Am  Surg  32 


498       EXCISION    OF    RIBS    AND    DIAPHRAGM    FOR    SARCOMA. 

The  section  surface  was  grayish,  homogeneous,  and  speckled  with  a 
few  hemorrhagic  and  opaque  necrotic  areas. 

Microscopical  examination  showed  in  general  a  round  of  elongated 
cellular  growth  with  a  little  fibrous  looking  intercellular  substance, 
through  which  were  scattered  innumerable  large,  multinucleated  cells. 
The  blood  seemed  to  circulate,  generally,  in  spaces  or  cavities,  but 
here  and  there  was  a  well-differentiated,  vascular  wall. 

Diagnosis.  Medullary  (giant-celled)  sarcoma,  evidently  originating 
in  the  rib. 


CASES  OF  LACERATION  OF  THE  SPLEEN  AND  OF 

THE  KIDNEY,  FOLLOWED  BY  RECOVERY 

AFTER  THE  REMOVAL  OF  THE 

INJURED  ORGAN. 


By  SAMUEL  J.  MIXTER,  M.D., 
BOSTON. 


F,  D.,  aged  twenty-five  years,  a  machinist  by  occupation,  at  11.30 
A.M.,  wliile  setting  up  a  locomotive,  was  struck  along  the  left  costal 
border  and  pinned  against  a  brick  wall  by  one  of  the  driving-wheels, 
which  fell  over  against  him. 

On  examination  shortly  afterward,  in  the  accident-room  of  the 
Massachusetts  General  Hospital,  he  was  found  to  be  a  well-developed 


Rupture  of  the  spleen  (Mixter's  case). 

man;  heart  and  lungs  normal;  general  condition  rather  poor;  he 
had  vomited  once,  normal  stomach  contents ;  abdomen  was  very  ten- 
der, especially  in  the  epigastrium,  and  there  was  dulness  in  both 
flanks;  slight  abdominal  rigidity;  no  external  mark  of  injury  save  a 
few  bruises  along  the  costal  border.  Temperature,  102.2°  F.  ;  pulse, 
104;   respiration,  30. 


500  MIXTER, 

An  incision  in  the  median  line  from  ensiform  to  three  inches  above 
pubis  showed  much  free  blood  in  abdominal  cavity.  Liver  first  exam- 
ined and  found  intact.  On  washing  out  with  salt  solution,  a  piece  of 
ruptured  spleen  was  found  free  in  the  abdominal  cavity.  A  trans- 
verse incision  was  made  to  the  left ;  another  free  piece  of  spleen  was 
found,  and  the  main  body  of  the  spleen  was  seen  to  be  torn  and 
hanging  by  a  few  shreds  of  tissue,  and  was  removed  without  ligation. 
The  splenic  artery  was  torn  and  spurting,  and  was  tied,  together  with 
the  splenic  vein.     Gauze  was  packed  into  abdomen  in  site  of  spleen. 

During  the  operation  a  quart  of  salt  solution  was  injected  into  a 
vein  in  the  arm.  The  patient's  pulse  fell  from  130,  at  the  end  of  the 
operation,  to  100  in  the  evening.  The  gauze  packing  was  removed 
on  the  fourth  day,  and  recovery  was  uneventful,  with  the  exception 
of  some  sepsis  in  the  external  wound,  due,  probably,  to  the  hurried 
preparation  before  the  operation. 

Fracture  of  the  Kidney ;  Nephrectomy ;  Recovery.  On  May  29, 
1899,  A.  C,  a  slight,  delicate  girl,  aged  ten  years,  while  crossing  a 
paved  street,  was  knocked  down  and  the  wheels  of  a  heavy  express 
wagon  passed  over  her  back.  She  was  taken  at  once  to  the  office  of 
Dr.  R.  W.  Lovett,  under  whose  care  she  had  been  for  slight  lateral 
curvature.  On  her  arrival  she  had  almost  no  pulse  and  seemed  to  be 
dying. 

I  saw  her  within  a  half-hour,  when  she  had  revived  a  little  under 
stimulation.  There  was  no  external  sign  of  injury.  The  abdomen 
was  tender,  rather  more  on  the  right  than  on  the  left,  and  rigid. 
After  a  time  she  passed  a  quantity  of  bloody  urine. 

She  was  at  once  removed  to  a  private  hospital  and  operated  upon. 

The  usual  lumbar  incision  exposed  an  infiltrating  hemorrhage  into 
the  deep  muscles  and  perinephritic  tissues,  and  a  rent  in  the  peri- 
toneum, through  which  a  large  quantity  of  blood  was  evacuated. 
The  torn  kidney  could  be  felt  at  the  bottom  of  the  wound,  was  drawn 
out,  and  the  few  shreds  of  tissue  by  which  it  was  attached  were  ligated 
and  the  mass  removed. 

It  was  found  that  this  represented  little  more  than  half  the  organ, 
and  the  hand  being  introduced  into  the  abdominal  cavity  found  the 
other  fragment  free  near  the  stomach.  This  was  removed,  the  abdo- 
men washed  out,  and  the  wound  partially  sutured  and  packed  with 
gauze. 

Recovery  was  uneventful,  and  the  cliild  had  suffered  no  inconveni- 


LACERATION  OF  THE  SPLEEN  AND  KIDNEY.    5OI 

ence  since  from  the  wound  or  the  loss  of  the  kidney.  Her  parents 
report  her  as  being  much  stronger  during  the  past  two  years  than 
before  the  accident. 

These  two  cases  are  reported  as  showing  the  extensive  com- 
minution of  an  abdominal  organ  that  may  take  place  without 
external  injury  or  immediate  fatal  hemorrhage,  and  the  value 
of  early  operation. 


SUBTROCHANTERIC    OSTEOTOMY    FOR    THE 

DEFORMITY   FOLLOWING    HIP 

DISEASE. 


By  E.  H.  BRADFORD,  M.D., 

BOSTON. 


The  natural  cure  of  hip  disease,  if  untreated,  inevitably  results 
in  a  characteristic  crippling  deformity,  with  marked  flexion  and 
abduction.  Even  in  the  treated  cases,  if  neglected  during  the 
convalescent  stage,  this  deformity  frequently  results. 

It  is  not  necessary  to  give  in  detail  the  history  of  the  develop- 
ment of  the  operation  for  the  correction  of  the  deformity,  as  the 
facts  are  well  known,  and  Gant's  operation  is  an  accepted  pro- 
cedure. The  object  of  this  paper  is  not  to  present  what  is  new, 
but  to  call  the  attention  to  some  of  the  practical  details  of  an 
operation  which  is  most  satisfactory  in  its  results,  not  difficult  of 
execution,  but,  unfortunately,  not  as  generally  employed  by 
the  surgical  profession  as  is  desirable.  The  following  case  will 
serve  as  a  type. 

A  young  man,  aged  eighteen  years,  suffered  from  hip  disease  when  a 
boy  aged  four  years.  The  usual  cmrse  of  abscesses  and  sinuses  followed, 
but  after  a  number  of  years  all  finally  healed,  and  he  was  left  with  a 
right-angle  deformity  of  the  thigh  with  severe  adduction.  He  was  able 
to  walk  with  one  crutch,  but  was  unable  to  place  the  whole  foot  upon 
the  ground.  There  were  many  cicatrices  of  old  sinuses  about  the  hip, 
subluxation,  and  an  actual  shortening  of  one  and  one-half  inches. 
Subtrochanteric  osteotomy  was  performed  and  the  limb  corrected  in 
the  manner  hereafter  described.  The  recovery  was  uneventful ;  the 
correction  of  the  deformity  has  been  maintained  without  recurrence 


SUBTROCH ANTEKIC  OSTEOTOMY.  5^3 

for  twelve  years  until  the  present  time.  He  is  now  able  to  walk  with 
perfect  freedom  without  crutch  or  cane,  with  no  practical  shortening 
of  the  affected  limb. 

It  is  unnecessary  to  give  the  histories  of  similar  cases,  vary- 
ing but  little  in  detail.  It  may  be,  however,  of  interest  to 
consider  the  best  manner  of  conducting  the  operation  and 
after-treatment. 

The  subject,  for  convenience,  may  be  limited  by  describing 
the  procedure  only  in  its  application  to  the  deformity  following 
hip  disease ;  where  there  is  ankylosis  at  the  hip,  either  osseous 
or  firmly  fibrous,  with  or  without  subluxation,  osteotomy  for 
coxa  vara  will  not  be  considered  here.  There  are  various 
methods  suggested  for  the  division  of  the  bone,  but  only  three 
need  to  be  mentioned  :  transverse  osteotomy,  oblique  osteotomy, 
and  wedge-shaped  section.  Of  these,  transverse  osteotomy  will 
be  found  satisfactory  in  the  cases  of  flexion  without  adduction, 
and  is  readily  performed.  In  ordinary  cases  no  preliminary 
incision  through  the  skin  is  necessary,  as  the  osteotome  can  be 
driven  to  the  bone  through  the  skn  with  a  slight  blow  of  the 
mallet.  The  place  for  the  entrance  of  the  osteotome  is  at  the 
level  of  the  lesser  trochanter,  or  slightly  below  this — that  is, 
below  the  insertion  of  the  psoas  and  iliacus  tendons.  It  is 
evident  that  where  osseous  ankylosis  has  taken  place  there  is 
little  danger  of  recontraction  whether  the  insertion  of  the  ten- 
don of  the  psoas  and  iliacus  is  below  or  above  the  break;  but 
even  under  these  circumstances  the  point  of  election  for  the 
division  of  the  bone  will  be  found  just  below  the  lesser  tro- 
chanter, on  account  of  the  greater  ease  of  the  division  of  the 
bone  at  this  point,  narrower  here  than  higher  up  on  the  femur. 

The  osteotome  is  driven  directly  to  the  bone  through  the 
skin  with  the  broad  axis  of  the  osteotome  parallel  with  the  axis 
of  the  thigh.  When  the  bone  is  reached  the  osteotome  is 
turned  in  the  hand  of  the  operator  and  driven  directly  through 
the  outer  layer  of  the  bone  to  the  medullary  layer.  After  the 
osteotome  is  well  engaged  in  the  bone  the  direction  should  at 
each  blow  be  turned  to  the  right  and  left,  so  that  it  will  cut  in 


504  BRADFORD, 

an  excursion  wider  than  the  width  of  the  osteotome,  and  to 
diminish  the  danger  of  the  hemorrhage.  The  division  of  the 
bone  is  continued,  working  from  the  cortical  layer  to  the  med- 
ullary layer,  the  difference  being  recognized  by  the  difference 
in  the  resistance  to  the  blows  of  the  mallet.  The  femur  should 
be  divided  from  one-half  to  three-quarters  of  its  thickness,  and 
the  rest  of  the  division  performed  by  the  fracture.  It  will  be 
found  to  be  easier  to  fracture  the  remaining  portion  of  the 
femur  by  first  moving  the  femur  by  adduction  and  flexion 
rather  than  by  abduction  and  extension,  though  after  the  bone 
is  fractured  the  limb  should  be  moved  in  the  direction  of  abduc- 
tion and  extension  to  stretch  the  contracted  soft  parts. 

The  width  of  the  osteotome  is  a  question  of  judgment,  some 
operators  preferring  a  narrow  osteotome  and  others  a  wider 
one.  The  corners  of  the  osteotome  should  be  rounded  to  pre- 
vent any  sharp  projection,  and  if  carefully  used  the  operation 
is  without  danger  of  hemorrhages. 

In  some  instances  it  will  be  necessary  to  perform  tenotomy 
or  open  incision  of  contracted  tissues,  but  usually,  especially  in 
children  and  adolescents,  these  tissues  can  be  readily  stretched. 
It  is  manifestly  a  neater  operation  if  the  osteotome  should  not 
be  reinserted,  but  that  all  the  cutting  by  the  osteotome  be  per- 
formed while  it  is  still  in  the  wound,  but  a  reinsertion  of  the 
osteotome  can  be  easily  made  if  a  sufficient  amount  of  the 
bone  has  not  been  divided  to  make  the  fracture  easy.  It  is 
manifestly  an  advantage  to  leave  a  certain  amount  of  the  bone 
uncut  to  be  fractured,  as  the  uncut  periosteum  helps  in  the 
needed  subsequent  union  of  the  fragments. 

Oblique  Osteotomy.  In  place  of  transverse  osteotomy  the 
bone  may  be  divided  obliquely,  entering  the  osteotome  slightly 
below  the  greater  trochanter,  directed  to  below  the  lesser  tro- 
chanter, from  without  inward  and  from  above  downward.  This 
is  advised  for  the  purpose  of  increasing  the  length  of  the  limb, 
employing  forcible  traction  for  the  purpose  at  the  time  of  the 
operation  or  during  after-treatment.  The  amount  of  lengthen- 
ing gained  in  this  way  is,  however,  limited  by  the  fascia  and 
shortened  muscles,  which  can  be  stretched,  and  by  the  lack  of 


SUBTROCHANTERIC  OSTEOTOMY.  505 

elasticity  of  the  uncut  periosteum.  If  the  periosteum  were 
entirely  severed,  firm  union  is  apt  to  be  delayed  or  interfered 
with,  a  complication  to  be  avoided. 

Oblique  osteotomy  has,  over  linear  osteotomy,  the  advantage 
of  furnishing  in  the  obliquity  of  the  fragment  an  obstacle  to 
the  slipping  inward  of  the  lower  fragment  if  the  limb  is  thor- 
oughly abducted.  Experience  enables  the  surgeon  to  determine 
by  the  sense  of  touch  the  correct  position  of  the  edge  of  the 
instrument,  and  with  ordinary  care  there  is  no  danger  of  hem- 
orrhage or  undue  injury  to  the  adjacent  tissues.  Wedge-shaped 
resection  of  the  femur  near  the  trochanter  has  no  practical  ad- 
vantage over  oblique  osteotomy,  and,  though  mechanically  cor- 
rect, is  surgically  unnecessary. 

Position  of  the  Osteotomized  Limb.  In  cases  with  adduction, 
or  when  there  is  much  subluxation,  oblique  osteotomy  is  pre- 
ferable to  linear,  but  after  either  has  been  performed  the  question 
of  the  position  in  which  the  limb  is  to  be  placed  is  of  the  great- 
est importance,  as  the  success  of  the  operation  naturally  depends 
upon  the  position  in  which  the  fragments  of  the  bone  are  placed 
for  reunion.  If  the  periosteum  is  but  little  injured,  it  is  well 
known  that  union  of  broken  bones  takes  place  finally,  even  if 
the  axis  of  the  fragment  differs  greatly  from  that  of  the  original 
bone. 

Nature's  fault  in  the  union  of  neglected  fractures  serves  as 
a  precedent  in  the  correction  of  the  deformity.  In  the  simplest 
cases  the  contractions  of  the  soft  parts  are  readily  overcome 
after  the  osteotomy  by  manual  effort.  If  the  deformity  is  not 
great,  and  that  chiefly  of  flexion  without  much  actual  shorten- 
ing, all  that  is  necessary  is  to  place  the  limb  in  a  position  nearly 
parallel  to  the  normal  bone,  and  allow  union  to  take  place.  If 
flexion  is  severe  the  fragments  do  not  remain  in  contact  after 
correction,  in  their  whole  cut  surface,  but  this  in  no  way  pre- 
vents a  firm  union  with  the  upper  or  lower  fragments,  forming 
an  angle  instead  of  a  straight  line,  the  callus  giving  sufficient 
solidity  for  future  use. 

Whether  the  limb  is  to  be  placed  in  a  position  in  a  plane 
with  the  long  axis  of  the  trunk,  or  slightly  flexed,  will  depend 


5o6  BRADFORD, 

upon  the  amount  of  flexibility  in  the  lumbar  spinal  column. 
If  the  latter  is  rigid  the  patient  will  find  difficulty  subsequently 
in  sitting  comfortably  if  the  flexion  is  completely  corrected. 
Ordinarily,  however,  especially  in  adolescents  and  children,  an 
exaggerated  amount  of  flexibility  has  been  developed  in  cases  of 
this  sort,  and  this  can  be  relied  upon  to  give  sufficient  amount 
of  change  in  the  position  of  the  thigh  relative  to  the  axis  of  the 
trunk  for  the  different  positions  incident  to  sitting,  standing, 
and  walking.  To  avoid  the  danger  of  this  it  is,  however,  de- 
sirable in  older  patients  to  place  the  thigh  in  a  position  of 
slight  flexion ;  not  more  than  fifteen  degrees  will  be  required 
for  this.  Where  the  limb  is  adducted  as  well  as  flexed  it  is 
necessary  to  place  the  limb  in  an  abducted  as  well  as  a  straight- 
ened position,  the  amount  of  the  abduction  depending  upon 
circumstances,  especially  the  amount  of  actual  shortening  of 
the  limb.  It  is  to  be  borne  in  mind  that  in  cases  of  severe 
distortion  after  hip  disease,  with  flexion  and  adduction,  tilting 
of  the  pelvis  takes  place,  the  affected  side  being  abnormally 
raised.  This  adds  a  practical  shortening  of  the  limb,  measur- 
ing from  the  umbilicus  to  that  given  by  the  flexion  of  the  limb, 
and  to  the  actual  shortening  from  subluxation.  If  this  abnor- 
mal tilting  of  the  pelvis  is  corrected  the  practical  shortening  is 
diminished,  and  if  this  tilting  of  the  pelvis  is  over-corrected,  so 
that  the  pelvis  is  tilted  in  the  direction  opposite  to  its  former 
position,  a  practical  lengthening  can  be  secured.  The  amount 
of  this  practical  lengthening  depends  upon  the  amount  of  pos- 
sible tilting  of  the  pelvis  in  the  corrected  direction.  This, 
again,  is  dependent  upon  the  lateral  flexibility  of  the  spinal 
column.  In  adolescent  cases  a  practical  lengthening  of  from 
two  to  three  inches  can  be  frequently  secured  in  this  way,  which 
is  frequently  enough  to  overcome  the  shortening  from  subluxa- 
tion and  also  from  arrest  of  growth  unless  this  is  unusually  great. 
The  operation,  if  done  without  preliminary  incision  down  to 
the  bone,  is  practically  a  subcutaneous  one,  and  the  dressing 
required  is  small  if  proper  aseptic  precautions  are  observed.  It 
is  usually  unnecessary  to  disturb  the  wound  until  several  weeks 
after  the  operation. 


SUBTROCHANTERIC  OSTEOTOMY.  5O7 

In  selecting  the  means  of  fixing  the  limb  after  osteotomy,  the 
decision  is  influenced  by  the  ease  with  which  the  correction 
has  been  obtained.  Where  there  are  few  contractions  of  the 
soft  part  and  the  fractured  limb  can  be  placed  easily  in  the 
desired  position,  it  will  be  found  most  serviceable  to  place  the 
patient  in  a  plaster-of-Paris  spica  with  the  affected  limb  strongly 
abducted,  if  the  previous  adduction  has  been  great.  The  sink- 
ing of  the  mattress  at  the  buttock  is  usually  sufficient  to  allow 
for  a  slight  amount  of  flexion,  which  is  ordinarily  desirable. 
The  advantage  in  a  plaster-of-Paris  bandage  consists  in  the  fact 
that  the  patient  is  placed  in  a  position  that  he  cannot  escape 
from.  There  is  less  danger  of  the  misplacement  of  the  frag- 
ments in  changing  the  patient's  position.  The  disadvantages 
of  plaster-of-Paris  bandages  lie  in  the  discomfort  caused  if  im- 
perfectly applied  and  in  the  fact  that  the  position  of  the  limbs 
cannot  be  readily  changed.  Where  complete  correction  is  not 
possible,  and  it  is  desirable  to  stretch  the  contraction  of  the  soft 
parts,  a  traction  appliance  can  be  used,  the  ordinary  weight  of 
the  pulley  being  the  most  convenient. 

The  amount  of  abduction  to  be  given  the  limb  varies  with 
the  amount  of  practical  lengthening  desired.  An  abduction  of 
forty-five  degrees  will  be  found  not  excessive  in  cases  of  severe 
distortion,  and  will  be  of  advantage  in  securing  practical 
lengthening. 

It  is  evident  that  where  the  limb  is  placed  in  an  over- 
corrected  position  after  severe  deformity,  it  will  be  necessary 
to  allow  considerable  time  before  expecting  complete  solidifica- 
tion, and  under  these  conditions  some  retentive  apparatus  is 
advisable.  Plaster-of-Paris  furnishes  a  suitable  support  for  this 
purpose,  but  as  a  substitute  a  stiffened  leather  splint  laced  upon 
the  trunk  and  thigh  will  answer.  It  is  not  safe  ordinarily  to 
allow  the  patient  to  bear  any  weight  upon  the  limb  until  ten  weeks 
after  the  operation,  and  in  larger  patients  where  the  deformity 
is  great  three  months  of  protection  is  preferred.  Locomotion 
by  aid  of  crutches  should  be  permitted  after  eight  weeks. 

It  is  evident  that  where  the  ossification  is  not  rapid,  danger 
of  relapse  exists.     This  should  be  prevented  by  obliging  the 


508  SUBTROCHANTERIC  OSTEOTOMY. 

patient  to  wear  retentive  apparatus  for  a  long  period,  even  after 
locomotion  with  crutches  is  allowed.  The  amount  of  time  that 
is  necessary  for  retentive  treatment  depends  upon  conditions 
not  easily  defined,  and  is  a  matter  of  judgment. 

It  is  desirable  that  the  operation  should  not  be  done  on  too 
young  or  on  rapidly  growing  patients.  The  yielding  character 
of  growing  bone,  and  its  inability  to  resist  deforming  pressure 
in  sitting  and  standing  may  cause  a  recurrence  of  the  deformity, 
a  danger  which  does  not  exist  in  older  patients.  An  unusual 
complication  may  be  mentioned — namely,  the  coexistence  of 
severe  knock-knee,  with  severe  adduction  and  flexion  of  the 
thigh,  following  hip  disease,  requiring  after  the  operation  at 
the  hip  a  second  osteotomy  at  the  knee,  but  with  a  successful 
result  in  the  end. 

In  fine,  the  operation  may  be  considered  as  most  satisfactory 
to  both  patient  and  surgeon,  correcting  the  deformity  and 
diminishing  a  humiliating  disability,  with  but  little  discomfort 
to  the  patient  and  no  greater  risk  than  that  following  a  fracture. 
The  demand  upon  the  surgeon  consists  simply  in  the  exercise 
of  skill  and  judgment  easily  acquired. 


IN  DEX. 


Abdominal  operations,  phlebitis  following,  223 
Abscess  of  lung,  pneumotomy  for,  482 
Address  of  the  President,  Park,  i 

Allis,  fractures  of  the  pelvis  from  violence  exerted  through  the  long  axis  of 

the  femurs,  being  a  comparative  study  of  the  relative  strength  of  the  neck 

of  the  femur  and  that  of  the  pelvis  when  the  violence  is  transmitted 

through  the  long  axis  of  the  former,  145 

Anaesthetic,  ether  as  an,  72 

Aneurisms,  aortic,  treatment  of,  by  means  of  silver  wire  and  electricity,  359 

traumatic  arterio-venous,  of  subclavian  vessels,  237,  286 
Apparatus  for  artificial  respiration  in  surgical  and  medical  practice,  410 

for  massive  infiltration  anaesthesia  with  weak  analgesic  solutions,  412 
Appendicitis,  clinical  value  of  blood  examinations  in,  60 
Arthrotomy  in  treatment  of  anterior  dislocation  of  tibia,  441 
Artificial   respiration  by  direct  intralaryngeal  intubation  with  a  modified 
O'Dwyer  tube  and  a  new  graduated  air-pump  in  its  applications 
to  medical  and  surgical  practice,  392 
use  of  Fell's  apparatus  for,  383 
Automatic  respiratory  apparatus,  408 

Bevan,  discussion  on  prevention  and  cure  of  post-operative  hernia,  312 

on  traumatic  arterio-venous  aneurisms  of  the  subclavian  vessels, 
292,  294 
Blake,  studies  of  the  blood  in  its  relation  to  surgical  diagnosis,  104 
Blood  changes  induced  by  the  administration  of  ether  as  an  anaesthetic,  72 
examination  of,  in  relation  to  surgery,  115 
examinations  as  an  aid  to  surgical  diagnosis,  122 

clinical  value  of,  in  appendicitis,  60 
studies  of  the,  in  its  relation  to  surgical  diagnosis,  104 
Bloodgood,  blood  examinations  as  an  aid  to  surgical  diagnosis,  122 
Bradford,  subtrochanteric  osteotomy  for  the  deformity  following  hip  disease, 

502 
Breast,  cancer  of,  treated  at  the  Johns  Hopkins  Hospital  since  1899,  26 
removal  of,  new  method  of  closing  the  wound  in  thorough  removal  of 
380 


5IO  INDEX. 

Brewer,  discussion  on  pancreatitis,  172 

Bryant,  influence  of  mental  depression  on  the  development  of  malignant 
disease,  43 

Cabot,  studies  of  the  blood  in  its  relation  to  surgical  diagnosis,  104 
Calculus,  double  renal,  377 

Cancer  of  breast,  cases  of,  treated  at  the  Johns  Hopkins   Hospital  since 
1899,  26 

cause  of,  57 

recent  Buffalo  investigations  regarding  the  nature  of,  i,  59 
Carcinoma  of  uterus,  early  signs  of,  24 
Carmalt,  discussion  on  thorough  removal  of  breast,  382 
Carson,  discussion  on  pancreatitis,  180 
Catheterization  of  ureters  in  the  male,  218 
Cicatricial  stricture  of  the  oesophagus,  450 
Chnical  value  of  blood  examinations  in  appendicitis,  60 
Coley,  discussion  on  operation  for  the  radical  cure  of  umbihcal  hernia,  305 

late  results  of  the  treatment  of  inoperable  sarcoma  with  the  mixed 
toxins  of  erysipelas  and  bacillus  prodigiosus,  27 

radical  cure  of  inguinal  and  femoral  hernia,  337,  358 
Cullen,  cause  of  cancer,  57 

early  signs  of  carcinoma  of  the  uterus,  24 
Curtis,  discussion  on  examination  of  the  blood  in  relation  to  surgery,  143 

Da  Costa,  John  Chalmers,  blood  changes  induced  by  the  administration 

of  ether  as  an  anaesthetic,  72 
Da  Costa,  J.  C,  Jr.,  clinical  value  of  blood  examinations  in  appendicitis,  60 
Deaver,  examination  of  the  blood  in  relation  to  surgery  of  scientific  but 

often  of  no  practical  value,  and  may  misguide  the  surgeon,  115 

Elliot,  discussion  on  pancreatitis,  178 

Estes,  discussion  on  pancreatitis,  181 

Ether  as  an  anaesthetic,  72 

Excision  of  a  part  of  three  ribs  and  a  portion  of  the  diaphragm  for  sarcoma, 

494 
Exhibition  of  methods  of  medical  instruction  in  the  Johns  Hopkins  Medical 
School  and  Hospital,  216 

Fell's  apparatus  for  artificial  respiration,  use  of,  383 
Finney,  discussion  on  double  renal  calculus,  379 

on  treatment  of  aortic  aneurisms  by  means  of  silver  wire  and  elec- 
tricity. 373 
Fowler,  discussion  on  pancreatitis,  179 

on  phlebitis  following  abdominal  operations,  234 


INDEX.  511 

Fractures  and  dislocations  of  spine,  314 

of  pelvis,  145 
Freeman,  discussion  on  pancreatitis,  182 

treatment  of  aortic  aneurisms  by  means  of  silver  wire  and  electricity, 
359.  375 

Gastro- ENTEROSTOMY,  vicious  circle  after,  417 

Gastrostomy  with  retrograde  dilatation  of  stricture  by  rubber  tubes,  450  , 
Gerrish,  discussion  on  operation  for  the  radical  cure  of  umbilical  hernia,  304 
Giant  sacrococcygeal  tumors,  444 

Halsted,  brief  consideration  of  cases  of  cancer  of  the  breast  treated  at  the 
Johns  Hopkins  Hospital  since  1899,  26 
discussion  on  radical  cure  of  inguinal  and  femoral  hernia,  357 

on  traumatic  arterio-venous  aneurisms  of  the  subclavian  vessels, 

-93 
Harris,  movable  kidney,  its  cause  and  treatment,  457 
Harte,  discussion  on  fractures  and  dislocations  of  spine,  335 
Hearn,  pneumotomy  for  abscess  of  lung,  482 
Hernia,  inguinal  aiid  femoral,  radical  cure  of,  337 

post- operative,  prevention  and  cure  of,  307 

umbilical,  operation  for  the  radical  cure  of,  296 
Hip  disease,  subtrochanteric  osteotomy  for  the  deformity  following,  502 
Hubbard,  studies  of  the  blood  in  its  relation  to  surgical  diagnosis,  104 

Infiltration  anaesthesia,  apparatus  for,  412 
Inguinal  and  femoral  hernia,  radical  cure  of,  337 

Inoperable  sarcoma,  treatment  of,  with  the  mixed  toxins  of  erysipelas  and 
bacillus  prodigiosus,  27 

Johns  Hopkins  Medical  School  and  Hospital,  methods  of  medical  instruc- 
tion in,  216 

Kalteyer,  blood  changes  induced  by  the  administration  of  ether  as  an 
anaesthetic,  72 

Keen,  resection  of  a  large  part  of  the  chest  wall  for  a  sarcoma  ;  use  of  Fell's 
apparatus  for  artificial  respiration ;  late  continuous  fever  due  to  staphylo- 
coccus blood  infection  ;  successful  use  of  the  antistreptococcic  serum  ; 
complete  recovery,  3S3 

Kelly,  necessity  of  employing  the  newer  methods  of  diagnosis  in  rectal  and 
urinary  diseases,  216 

Kidney,  laceration  of,  499 

movable,  its  cause  and  treatment,  457 

Laboratory  methods  of  teaching,  219 
Laceration  of  spleen  and  kidney,  499 


512  INDEX. 

Lange,  discussion  on  phlebitis  following  abdominal  operations,  236 
Lung,  abscess  of,  pneumotomy  for,  482 

McCoSH,  discussion  on  operation  for  the  radical  cure  of  umbilical  hernia, 

305 
McGraw,  discussion  on  traumatic  arterio-venous  aneurisms  of  the  subclavian 
vessels,  294 
two  cases  of  vicious  circle  after  gastro-enterostomy,  417 
Mahgnant  disease,  influence  of  mental  depression  on  the  development  of,  43 
Matas,  an  apparatus  for  massive  infiltration  anaesthesia  with  weak  analgesic 
solutions  (modified  Schleich  method),  412 
artificial  respiration  by  direct  intralaryngeal  intubation  with  a  modified 
O'Dwyer  tube  and  a  new  graduated  air-pump  in  its  applications  to 
medical  and  surgical  practice,  392 
discussion  on  treatment  of  aortic  aneurisms  by  means  of  silver  wire  and 

electricity,  374 
traumatic  arterio-venous  aneurisms  of  the  subclavian  vessels,  237,  286, 
294 
Mayo,  discussion  on  phlebitis  following  abdominal  operations,  235 
on  surgical  treatment  of  chronic  ulcer  of  the  stomach,  213 
operation  for  the  radical  cure  of  umbilical  hernia,  296,  306 
Mental  depression,  influence  of,  on  the  development  of  malignant  disease,  43 
Method,  new,  of  closing  the  wound  in  thorough  removal  of  breast,  380 
Mixter,  cases  of  laceration  of  spleen  and  of  kidney,  499 
discussion  on  fractures  and  dislocations  of  spine,  335 
double  renal  calculus,  377 

new  method  of  closing  the  wound  in  thorough  removal  of  breast,  380 
Moore,  prevention  and  cure  of  post-operative  hernia,  307,  313 
Movable  kidney,  its  cause  and  treatment,  457 
Munro,  discussion  on  fractures  and  dislocations  of  spine,  333 

Necessity  of  employing  the  newer  methods  of  diagnosis  in  rectal  and 
urinary  diseases,  216 

OCHSNER,  discussion  on  operation  for  the  radical  cure  of  umbilical  hernia, 

301 
CEsophagus,  cicatricial  stricture  of,  450 
Operation  for  the  radical  cure  of  umbilical  hernia,  296 
Opie,  discussion  on  pancreatitis,  176 
Osteotomy,  subtrochanteric,  502 

Pancreatitis,  149 

Park,  the  recent  Buffalo  investigations  regarding  the  nature  of  cancer,  i,  59 

Pelvis,  fractures  of,  145 


INDEX.  513 

Phlebitis  following  abdominal  operations,  223 

Pontico,  discussion  on  fractures  and  dislocations  of  spine,  335 

Porter,  excision  of  a  part  of  three  ribs  and  a  portion  of  the  diaphragm  for 

sarcoma,  494 
Post-operative  hernia,  prevention  and  cure  of,  307 
Powers,  giant  sacrococcygeal  tumors,  444 
P;esident's  address,  Park,  i 
Prevention  and  cure  of  post-operative  hernia,  307 

Radical  cure  of  inguinal  and  femoral  hernia,  337 

Recent  Buffalo  investigations  regarding  the  nature  of  cancer,  i,  59 

Rectal  and  urinary  diseases,  necessity  of  employing  the  newer  methods  in, 

216 
Renal  calculus,  double,  377 

Resection  of  a  large  part  of  the  chest  wall  for  a  sarcoma,  383 
Roberts,  anterior  dislocation  of  tibia  treated  by  arthrotomy,  441 
Robson,  pancreatitis,  149,  182 

surgical  treatment  of  chronic  ulcer  of  the  stomach,  184,  215 
Redman,  discussion  on  surgical  treatment  of    chronic  ulcer  of  stomach, 

214 
Roe,  pneumotomy  for  abscess  of  lung,  482 

Sacrococcygeal  tumors,  444 
Sarcoma,  inoperable,  treatment  of,  27 

resection  of  a  large  part  of  the  chest  wall  for  a,  383 
Schleich  method,  modified.  412 

Silver  wire  and  electricity  in  treatment  of  aortic  aneurisms,  359 
Spine,  fractures  and  dislocations  of,  314 
Spleen,  laceration  of,  499 
Stomach,  ulcer  of,  surgical  treatment  of,  184 
Stricture,  cicatricial,  of  cEsophagus,  450 
Studies  of  the  blood  in  its  relation  to  surgical  diagnosis,  104 
Subtrochanteric  osteotomy  for  the  deformity  following  hip  disease,  502 
Surgical  treatment  of  chronic  ulcer  of  the  stomach,  184 

Tibia,  anterior  dislocation  of,  treated  by  arthrotomy,  441 

Traumatic  arterio-venous  aneurisms  of  the  subclavian  vessels,  237,  286 

Tumors,  giant  sacrococcygeal,  444 

Turner,  discussion  on  phlebitis  following  abdominal  operations,  235 

Ulcer  of  stomach,  chronic,  surgical  treatment  of,  184 
Umbilical  hernia,  operation  for  the  radical  cure  of,  296 
Ureters,  catheterization  of,  219 
Uterus,  carcinoma  of,  early  signs  of,  24 

Am  Surg  :?3 


514  INDEX. 

Vaxder  Veer,  phlebitis  following  abdominal  operations,  223,  235 
Vicious  circle  after  gastro-enterostomy,  417 

Warren,  discussion  on  operation  for  the  radical  cure  of  umbilical  hernia. 
306 

on  radical  cure  of  inguinal  and  femoral  hernia,  356 

on  thorough  removal  of  breast,  382 
Weeks,  fractures  and  dislocations  of  spine,  314,  336 
Welch,  laboratory  methods  of  teaching,  219 
Wharton,  cicatricial  stricture  of  the  oesophagus,  450 
Willard,  discussion  on  operation  for  the  radical  cure  of  umbilical  hernia,  304 

on  treatment  of  aortic  aneurisms  by  means  of  silver  wire  and  elec- 
tricity, 374 

Young,  catheterization  of  ureters  in  the  male,  218 


* 


1 


I 


BJNDIKG  SZCT.  JAN5    1972. 


RD 

1 

V.19 

Biological 
&  Medical 
Serials 


American  Surgical  Association 
Transactions 


P 


PLEASE  DO  NOT  REMOVE 
CARDS  OR  SLIPS  FROM  THIS  POCKET 

UNIVERSITY  OF  TORONTO  LIBRARY 


I 


STORAGE 


.■■M.N-y;.ryi-.fc...T^-.